Farm Animal Ultrasonography1PDF

IN THE NAME OF ALLAH,
MOST GRACIOUS, MOST MERCIFUL

College of Agriculture and Veterinary
Medicine
Department of Veterinary Medicine
Farm Animal Ultrasonography

Principles. Medicine. Reproduction. Eye & Musculoskeletal.
Bovine. Equine. Ovine. Caprine. Camelids.
Ahmed Ali Mohamed Tharwat Fahd Al-Sobayil

‫صفحة الردمك‬
© King Saud University, 2013
King Fahd onal Library Cataloging-in-Publication Data
Al-Naami, Mohammed Y.
Trauma care system in Saudi Arabia: an agenda for action. / Mohammed Y Al-Naami; Maria A Arafah;
Fatimah S Al-Ibrahim – Riyadh, 2013
204 p., 21 x 28 cm
ISBN: 978-603-507-153-6
1- Traumatology 2- Trauma centers – Saudi Arabia

I-Maria A Arafah (co.author) II-Fatimah S Al-Ibrahim
(co.author) III-Title
617.156 dc 1434/7656
L.D. No. 1434/7656

ISBN: 978-603-507-153-6
Dedication
“To my family.
To the veterinarian, students, and colleagues.”
Ahmed Ali
“To my parents, my wife, and my children:Samia,

Ahmed, Abdel-Rahman, and Salma.
To the filed veterinarians and veterinary students.”
Mohamed Tharwat
“To my family.
To the veterinarians and veterinary students.”
Fahd Al-Sobayil
 v 
Preface
Veterinary ultrasound has grew from an exotic imaging modality in the late 1970s to an
essential service at clinics, hospitals, and many private veterinary practices. The sonographic
progress provided the stimulus for writing this book so as to illustrate the possibilities and
limitations of application of ultrasonography in veterinary medicine.
It is becoming apparent that ultrasound diagnostic in veterinary medicine may
experience the same kind of development as it had in human medicine where it was first
applied in gynecology at the end of 1958 and since then it had expanded into virtually all
fields of diagnostics.
Much of this book is based on personal experiences and observations. Our main goal is
to help advances and to promote veterinary ultrasound to new and higher levels. Its purpose is
to serve as a general source on veterinary ultrasound for students, on the basis of a more
complete, comprehensive reference for residents and practitioners.
This book includes all aspects of the veterinary subjects in which ultrasound should be
used. It includes 4 major parts, namely general physical principles of ultrasound;
ultrasonography and veterinary internal medicine; ultrasonography of the female and male
reproductive tracts of farm animals; and ultrasound of the eye, orbit, and musculoskeletal
system. All farm animals are included in this book, namely bovine, equine, ovine, caprine,
and camelids.
We are grateful to the following people for their suggestions during the processing of
this book: Dr. A Al-Hawas, Dr. A F Ahmed, and Dr. O El-Tookhy. Moreover, we would like
to thank the president of Qassim University, the Dean of the College of Agriculture and
Veterinary Medicine, and the Head of the Department of Veterinary Medicine at Qassim
University for their invaluable support to such scientific books at Qassim University.
The Authors
 vii 
Table of Contents
Part I: General physical principles of ultrasound 1
Glossary 1
Ultrasound waves 3
Ultrasound generation 4
Scanner controls 5
Display of images on screen 6
Image interpretation 7
Ultrasound probe 8
Modes of echo display 11
Real-time Ultrasonography 13
Tissue – ultrasound waves interaction 14
Attenuation of the soundbeam 15
Imaging Artifacts 16
Part II: Ultrasonography and Veterinary Internal Medicine 23
Chapter 1: Ultrasonography of the Cardiovascular System 23

Introduction 23
Imaging technique 23
Echocardiography 24
Normal echocardiographic examination 26
Practical Application of Echocardiography 30
Congenital heart disease 30
Acquired heart disease 32
Practical ultrasonography of the vascular system 39
Chapter 2: Ultrasonography of the Respiratory System 40
Introduction 40
Physiological appearance of the lungs and pleura 41
Ultrasonographic appearance of thoracic pathologies 42
Chapter 3: Ultrasonography of the Digestive System 48
Introduction 48
Ultrasonographic examination of the digestive system in ruminants 48
Normal reticulum 48
Ultrasonography of the normal spleen 49
Abnormal appearance 50
Reticular abscesses 53
Intestine 54
 ix 
Contents
Ileus of the small intestine 55

Ultrasonography of the equine abdomen 57
Limitations 57
Ultrasonographic techniques for imaging equine abdomen 58
Normal ultrasonographic findings 59
Ultrasonographic features of the small intestine 60
Ultrasonographic features of the cecum 61
Ultrasonographic features of the large intestine 62
Ultrasonographic findings in the colic horse 63
Other abdominal disorders detected by ultrasonography 66
Chapter 4: Ultrasonography of the Liver 73
Introduction 73
Normal appearance 74
Diffuse hepatic disease 76
Fatty liver disease 76
Hepatic fibrosis 79
Focal disease 80
Hepatic abscess 80
Bile ducts and gallbladder abnormalities 81
Calcification of the bile duct 81
Cholangitis, and cholestasis 82
Caudal vena cava 85
Thrombosis of the caudal vena cava and hepatic vein 86
Chapter 5: Ultrasonography of the Pancreas 89
Introduction 89
Imaging procedure 89
Pancreatic biopsy 90
Pancreatitis 91
Pancreolithiasis 92
Pancreatic fat necrosis 93
Pancreatic abscess 94
Chapter 6: Ultrasonographic Examination of the Urinary System 95
Introduction 95
Kidneys 95
Renal cysts 98
Collecting system, pelvis and ureters 99
Hydronephrosis 99
Pyelonephritis 100
Renal calculi 100
Urinary bladder 101
Imaging procedure, normal and abnormal appearance 101
Cystitis 104
x
Contents
Bladder content 105

Ultrasonography in males with urethral obstruction 108
Suggested reading 109
Part III: Female and Male Reproductive Ultrasonography 113
Chapter I: Female Reproductive Tract Ultrasonography 113

I: Ultrasonography of the reproductive tract of the mare 115
Technique of examination 115
Ovarian structure in the mare 117
1. Follicles 117
2. Corpus luteum 118
3. luteinized follicles 120
4. Hemorrhagic follicles 120
5. First ovulation in seasonal breeding mare 120
6. Anestrous 121
Uterine structures in the mare 121
1. non-pregnant uterus 121
2. Pregnant uterus 122
II: Ultrasonography of reproductive tract of Cow and Buffalo-cow 133
Technique of examination 134
Ovarian structures in the cow 135
1. Follicle 135
2. Corpora lutea 136
3. Ovarian cysts 138
4. Ovarian tumors 139
Uterine structures in the cow and buffalo-cow 139
1. Non-pregnant uterus 139
2. Pregnant uterus 141
3. Fetal sex determination 153
4. Uterine pathology 163
III: Ultrasonography of the reproductive tract of the Ewe and Doe 166
1. Technique of examination 166
2. Examination of the ovaries 169
3. Follicular dynamic and luteal development in sheep 169
4. Examination of non-pregnant uterus 172
5. Pregnancy diagnosis and fetal development 175
6. Postpartum uterine involution and onset of luteal activity for sheep in
181
the subtropics
7. Uterine pathology 183
VI: Ultrasonography of the reproductive tract of the Female Camel 185
1. Introduction 186
2. Topography of the reproductive tract 186
3. Ovarian follicular dynamics 187
4. Non pregnant and pregnant uterus 188
5. Diseases of the female reproductive tract 192
V: Ultrasonographic ovum pick-up 195
Chapter II: Male Reproductive Tract Ultrasonography 199
xi
Contents
I: Ultrasonography of the Male Reproductive Tract of the stallion 199

1. Ultrasonographic examination of the scrotal contents 200
2. Ultrasonographic examination of the internal reproductive organs 201
II: Ultrasonography of the Reproductive Tract of the Cow-Bull and Buffalo-
203
Bull
1. Anatomy of the genital tract of the bull 203
2. Ultrasonic assessment of development of genital tract in bull 204
A. Scrotal contents 204
B. Internal reproductive organs 207
III: Ultrasonography of the Reproductive Tract of the Ram 211
1. Anatomy of the reproductive tract of ram 211
2. Ultrasonic assessment of development of the genital tract in ram 212
VI: Ultrasonography of the Reproductive Tract of the Male Camel 215
1. Anatomy of the male reproductive tract in male camels 215
2. Ultrasonic assessment of development of the genital tract in male
216
camel
Part IV: Ultrasonography of the Eye and Musculoskeletal system

225
Chapter 1: Ultrasound of the Eye and Orbit
Normal Anatomy 225
Examination Technique 226
The corneal technique (The transcorneal) 227
The eyelid technique (The transpalpebral) 227
Ultrasonographic Appearance of the Normal Eye 228
Abnormalities 230
Cornea 230
Iris/ciliary body 231
The lens 232
The vitreous and intraocular masses 234
The retina 234
The tissues posterior to the globe 235
Chapter 2: Tendons & Ligaments 237
Flexor tendon and ligaments 237
The Procedure of ultrasound examination 239
Chapter 3: The Joints 254
Patient Preparation and Scanning Technique 254
Synovial Joint 254
The Temporomandibular Joint 255
Chapter 4: The Neck 256
Chapter 5: The fore-limb 258
Shoulder Joint 258
Elbow Joint 259
Carpal Joint 263
Fetlock Joint 264
Pastern Joint 271
The Foot (Coffin Joint) 272
xii
Contents
Chapter 6: The Back 274

Chapter 7: The Pelvis 275
Chapter 8: The hind limb 275
Hip Joint 275
Stifle Joint - Femoropatellar Joint 275
Medial and Lateral Femorotibial Joints 276
Hock Joint 281
Chapter 9: Ultrasonography of Orthopedic (Non-Articular) Structures 288
Bone 288
Osteomylitis 288
Incomplete Ossification of the Cuboidal Bones 290
Foreign Bodies and Draining Tracts 290
Chapter 10: Muscles 292
Normal Ultrasonographic Appearance of Skeletal Muscle 292
Abnormal Ultrasonographic Findings of Skeletal Muscle 292
Muscle Injuries 292
Myopathy 293
Muscle Neoplasms 294
Subject index 299
Authors Biographies 301
xiii
Part I
General Physical Principles of Ultrasound

By
Ahmed Ali (BVSc, MVSc, PhD-Germany)
Mohamed Tharwat (BVSc, MVSc, PhD-Japan)
Glossary
Absorption: Loss of energy, principally due to molecular friction forces and production of
heat. As frequency increases, absorption increases.
Acoustic coupling: Since ultrasound is poorly transmitted through air it is necessary to
exclude air and link the transducer to the surface of the subject with a suitable coupling gel.
Acoustic enhancement: Tissues distal to an anechoic structure may display enhanced
echogenicity.
Acoustic interface: Junction of two tissues with different acoustic impedance. This leads to
the reflection of a proportion of the incident beam and possible diffraction of much of the
remainder of the beam. The greater the difference in acoustic impedance, the stronger the
reflection.
A-mode: Amplitude modulation. A one-element (one-dimentional) display with time
(distance) on the horizontal axis. The relative strength of the echo is registered as amplitude
on the vertical axis.
Amplitude: Height of the ultrasound waveform.
Anechoic: A tissue failing to reflect the ultrasound beam produces no echoes (e.g. a fluid-
filled structure).
Array: Distribution of crystals along the length of a linear scan head.
Artifact: An on-screen representation of a structure which does not exist or is incorrectly
located.
Attenuation: Decrease in power of the ultrasound beam, caused principally by absorption,
scatter and reflection.
Axial resolution: Measure of the ability of the system to differentiate two structures lying
together along the path of the ultrasound beam.
B-mode: Brightness modulation. A compound A-mode scan with amplitude translated into a
brightness scale. Location on the display is related to position and depth.
Diffuse reflection: An echo from target less than one wavelength in size>
Doppler ultrasound: When an ultrasound beam meets a moving object the reflected
ultrasound is either of increased or decreased frequency, depending on whether the motion is
1
2 Farm Animal Ultrasonography
towards or away from the transducer. Either continuous or pulsed Doppler can be used and
some systems can display compound information.
Echogenic: A structure causing a marked reflection of the ultrasound beam.
Focal area: Region of the scanned field where resolution is greatest.
Frame rate: The frequency with which images are updated on the screen.
Frequency: Number of ultrasound waves emitted per second. 1 cycle per second = 1 hertz
(Hz).
Gain: The amplification level of a returned signal. On some instruments different depth of the
field are handled separately. Incorrect setting of gain control will lose detail from fine
structures.
Gray scale: Range of intensities displayed on the cathode ray tube.
Hyperechoic: Showing increased echogenicity.
Hypoechoic: Showing decreased echogenicity.
Lateral resolution: Measure the ability of the system to differentiate two structures lying
side-by-side at the same distance from the transducer.
Linear array: Distribution of piezoelectric crystals along the length of a scan head. The image
produced is generally rectangular.
M-mode: Motion mode. Essentially a rapidly updated one-dimensional B-mode display with
time on the second axis to allow study of moving structures, used principally in cardiology.
Piezoelectric crystals: Crystals of materials such as lead zirconate-titanate, capable of
converting applied electrical energy to mechanical deformation and vice versa.
Power: Energy of the ultrasound beam.
Probe: The transducer array and its housing.
Real-time: Images generated from reflected ultrasound following sequential activation of the
transducer array are displayed on the screen at sufficient speed to give the appearance of a
live image.
Reverberation echo: An artifact created by the retransmission of a strongly reflected
ultrasound signal. The display may show several images of a single structure, which appear at
increasing distances from the transducer.
Scan converter: A component of the processing system which converts the electrical output
of the scanner of the transducer to the cathode ray tube image, essentially by aggregating
sequential arrays across the screen. A scan converter allows for subsequent analysis beyond
display (post-processing) and the use of standard TV accessories.
Scatter: When the ultrasound beam encounters a small object in its path the beam energy is
spread all directions.
Sector scan: A pieslice/sector shaped image is produced on the screen. The intial signal is
produced by a single vibrating piezoelectric crystal or a small number of rotating crystals. The
scan head needs only a limited contact area.
General Physical Principles of Ultrasound 3
Shadowing: Caused by severe attenuation of the ultrasound beam such that it fails to
penetrate sufficiently deep.
Specular reflection: A strong echo created by a highly reflective tissue interface representing
an area significantly larger than one wavelength.
Time-gain compensation (TGC): Since the ultrasound beam is increasingly attenuated as it
travels deeper into tissue, by applying TGC tissues of similar reflection are presented with
similar brightness, regardless of distance from the transducer.
Transducer: The piezoelectric crystal or element which converts electrical to acoustic energy
and vice-versa.
Ultrasound: Sound of a frequency above that perceived by the human ear
Hyperechoic, high echo intensity, or echo-rich: Areas of high echo intensity.
Echo-poor or hypoechoic: Areas of low echo intensity.
Echo-free or anechoic: Areas with no echoes.
Acoustic shadowing or distal acoustic enhancement: it is commonly used to describe high or
low sound attenuation by evaluating the echoes deep to a mass.
Fine and coarse parenchymal textures: Are used to refer to small or large dot size,
respectively.
A uniform texture: Suggests similar size and spacing of dots throughout the parenchyma.
A nonuniform texture: Suggests that the dot size, spacing, or both may be varying throughout
the parenchyma.
Uniform and non-uniform (homogenous and non-homogenous): Refer to either
echogenicity or texture.
Ultrasound Waves
Ultrasound is a high-frequency sound wave. Audible sounds are of the order 20 to
20.000 herz (cycle/second), while ultrasound waves are of a higher frequency (Fig. A-1). For
diagnostic application, frequencies of 1-10 MHz are employed. Like audible sound,
ultrasound cannot be propagated in a vacuum and in gas transmission. Reflection of
ultrasound occurs between substances of different types of acoustic impendence (defined as
the product of the velocity of ultrasound in a substance and the density of the latter).
Ultrasound can be propagated in an elastic medium primarily as longitudinal compressing
waves. By means of the echo principle, an image can be produced on the display of the
scanner which relates to the acoustic impendence of tissues encountered by the ultrasound
beam and the depth / distance of tissue interface (Fig. A-2).
Fig. A-1: Schematic representation of sound waves. The upper one: High-frequency sound wave. The wavelength is the distance
covered by one sound wave during one cycle. The lower one: Low frequency sound wave. The wave length is longer
(www.biometricsltd.com).
Fig. A-2. Schematic illustration of the reflection of an ultrasound pulse emitted from the probe P, being reflected at a, b and c.
Part of the pulse energy is transmitted from the scattered a, the rest is transmitted, part from b and the rest from c.
When the pulse returns to P, the reflected pulse gives information of two measurements: The amplitude of the
reflected signal, and the time it takes returning, which is dependent on the distance from the probe (twice the time
the sound uses to travel the distance between the transmitter and the reflector, as the sound travels back and forth).
The amount of energy being reflected from each point is given in the diagram as the amplitude. When this is
measured, the scatter is displayed with amplitude and position. Thus, the incoming pulse a a is the full amplitude of
P. At b, the incoming (incident) pulse is the pulse transmitted through a. At c, the incident pulse is the transmitted
pulse from b. (In both cases minus further attenuation in the interval) (Goddard, 1995).
Ultrasound Generation
The crystals in the transducer (piezoelectric effect) are vibrated when a high voltage
electrical current is applied and ultrasound is generated (Fig. A-3). The frequency of vibration
of the ultrasound waves is related to crystal characteristics. Frequency of emission and
wavelength are inversely proportional. This relationship has consequences for penetration of
tissue and definition of detail: as frequency increases, the ability to differentiate objects along
the path of the beam (axial resolution) increases, but the beam is more rapidly attenuated
(reduced in power).
Fig. A-3: ultrasound generation.
Ultrasound is transmitted to the patient from the transducer and propagates through the
tissue. The velocity of propagation depends on the tissue characteristics. It is reflected by
structures normal to the beam axis, and nearer boundary echoes return first. The returning
ultrasound meets with and deforms the crystals in the transducer. This mechanical energy is
converted back to an electrical signal proportional to the strength of the echo and delayed by a
time roughly proportional to the distance travelled. The reflected signals are interpreted by the
instrument as variations in brightness displayed on the cathode ray tube of a B-mode system.
Since ultrasound travels in a straight line, a composite of two-dimensional image can be
achieved.
Scanner Controls
Ultrasound is based on the pulse-echo principle. A pulse of sound is emitted from the
transducer after a special piezoelectric crystal contained within the scanhead is vibrated and
quickly dampened. The pulse repetition frequency is the number of pulses occurring in 1
second. The frequency of sound emitted depends on crystal inherent characteristics. The
crystal’s vibrations are immediately dampened by a backing block so that only a short pulse
length of two to three wave-length is emitted. The crystal then remain quiet while waiting for
returning echoes reflected from tissues within the body. These echoes vibrate again,
producing small voltage signals that are amplified to form the final image. A timer is
activated at the moment the crystal is pulsed so that the time of each echo’s return can be
determined separately and placed at the appropriate location on the video monitor. The
elapsed time represents the distance (depth) from the transducer where a particular echo
originated.
A dot representing each returning echo is placed on the video monitor at the appropriate
depth according to the time it took for the echo to return. A gray scale is also assigned to each
dot corresponding to the amplitude or strength of the returning echo. Very low-intensity
echoes is displayed as near black, medium intensity echoes as various shades of gray, and
high-intensity echoes as white (white-on-black display).
The ultrasound beam and the returning echoes are attenuated as they pass through
tissues. The farther away a reflecting interface is from the transducer, the weaker will the
returning echo be. The ultrasound scanner’s controls are designed either to increase the
intensity of sound transmitted into tissues or to electronically amplify returning echoes to
compensate for this attenuation. In some cases, these controls are also used to suppress strong
echoes returning from superficial structures in the near field. The prime objective of
manipulating the scanner is to produce a uniform image brightness throughout the near and
far field.
Display of Images on Screen

Each echo position is represented as a dot on the screen. Thus a two-dimensional image
is generated. The brightness (and hence B-mode: brightness mode) of each dot is related to
the amplitude of the reflection and is referred to as a grey scale display. Individual
instruments can vary in the number of divisions of the grey scale (from black to white) they
are able to generate.
A scan converter changes the format of the scan from the way it is produced at the
source to the way it is displayed. In electronic terms it may be described as being six or eight
bits deep, allowing 64 or 256 shades of grey respectively in each pixel on the screen.
Because of attenuation, deeper tissues could be expressed to produce less reflection and
consequently less bright images on the screen bright images on the screen, regardless of their
density. In order not to confuse visual interpretation, instruments adopt a time-gain
compensation adjustment which automatically amplifies signals that have a longer round-trip
time.
Although the image appears to be live (real-time), it is in fact a constantly updated fixed
image, the speed of which is defined by the frame rate. There are usually two frame rates, the
scanning frame rate and the display frame rate (Fig. A-4).
Fig. A-4: The CPU is the brain of the ultrasound machine. The CPU is basically a computer that contains the
microprocessor, memory, amplifiers and power supplies for the microprocessor and transducer probe. The CPU
sends electrical currents to the transducer probe to emit sound waves, and also receives the electrical pulses from
the probes that were created from the returning echoes. The CPU does all of the calculations involved in
processing the data. Once the raw data are processed, the CPU forms the image on the monitor. The CPU can
also store the processed data and/or image on disk. The transducer pulse controls allow the operator, called the
ultrasonographer, to set and change the frequency and duration of the ultrasound pulses, as well as the scan
mode of the machine. The commands from the operator are translated into changing electric currents that are
applied to the piezoelectric crystals in the transducer probe.
Ultrasound is not emitted from the transducer continuously in B-mode diagnostic

situations. If it were it would be impossible to interpret the returning signals. A pulse-echo
system is employed. A pulse of ultrasound (comprising around 5-6 wave cycles typically
lasting less than one microsecond) is emitted and its reflection received prior to emission of
the next pulse. The frequency of pulse emission is governed by the speed of ultrasound in
tissue and the total time needed for the ultrasound pulse to cover its outward and return
journeys (the round-trip time). For real-time (live) ultrasonography, as high a pulse frequency
as possible, is adopted up to a theoretical maximum of around 2000 Hz. It is important to use
a high quality pulse of uniform frequency.
The ability of the system to differentiate two structures along of the bean is described as
the axial resolution (Fig. A-5). It is improved by shorter pulse duration. Since the number of
cycles in each pulse is usually fixed by the design of the instrument, the only way the
sonographer can improve axial resolution is to increase the frequency. Lateral resolution, the
ability of the system to differentiate two structures lying side-by-side, is related to the size of
the transducer elements and the frequency (Fig. A-5). It is optimal at the focal length, where
the beam is thinnest, and like axial resolution, it improves as frequency increases. In practice,
reducing the gain may improve lateral resolution.
Fig. A-5: Lateral and axial resolution (Goddard, 1995).
Image Interpretation
Ultrasound is a technique that images anatomy in any described tomographic plane.
Therefore, the sonographer must be familiar with normal three-dimensional anatomy to
recognize artifacts, interpret normal variations, and detect pathologic changes.
Blood or fluid that does not contain cells or debris is black because few echoes are
returned. As fluid gains viscosity from increased protein cells, or debris, it becomes
progressively more echogenic. Normal parenchymal organs and body tissues are visualized as
various shades of gray, which is fairly constant from animal to animal. Fat is generally
thought to be highly echogenic. Connective tissue usually appears highly echogenic (Fig. A-
6). Regions distal to highly attenuating structures such as bone or gas appear dark on the
image because of shadowing. Artifacts such as shadowing must be differentiated from actual
echo-poor regions produced by fluid or necrosis. Areas distal to regions of low attenuation
may appear bright due to an artifact termed "echo enhancement". This appearance must not be
confused with regions of actually increased echogenicity.
Watery Fluid Viscous Fluids Bone
Fig. 1-6: Interpretation the ultrasound gray shades
Ultrasound Probe
Piezoelectric material is the main part of the transducer (Fig. A-7), which generates the
ultrasound pulses across its narrow axis and sends a thin beam of the ultrasound into receptive
tissues. A number of piezoelectric materials exist naturally, or have been manufactured. Lead
zirconate-titanate (PZT) is considered one of the best, although it does not naturally exist. The
frequency of the transducer is generally fixed and is related to the thinness (usually less than 1
mm) of the piezoelectric material. For diagnostic work, frequencies 1-10 MHz are adopted.
Fig. A-7: Piezoelectric material (www.sonochemistry.inf).
Linear transducers consist of a number (64-256) of such piezoelectric crystals precisely

aligned the long axis of the probe. When exited, these produce a plane wave front of
ultrasound emission. The linear-array scanner is an electronic scanner with multiple crystals
arranged in a line within a bar-shaped scanhead. The narrow beam is swept through a
rectangular field by firing the transducer's crystals sequentially in order. Usually more than
one crystal is fired at a time in a sequence, but there are no moving parts. Hence, this type of
scanner is very reliable. In variation of this type of scanner, the crystals are arranged in a
curved arc instead of a straight line to give a wider angle of view. The shape of the image
depends on the curvature of the arch. Linear-array scanners usually cost less than sector
scanner, unless more sophisticated phased-array technology is used to steer and focus the
beam.
Some transducers are capable of multifrequency operation. These transducers have

multiple crystals, but each emits a different frequency. However, only one crystal is selectable
by the sonographer at a particular time. In a linear array multi-element transducer, not all the
crystals may be excited simultaneously. They are either triggered sequentially along the
length or segmentally in overlapping blocks. Segmental activation optimizes beam quality.
Ultrasound wave can be focused. Focusing can be achieved by adjusting the physical shape of
the transducer face, which may have a superficial concave acoustic lens (Fig. A-8).
Fig. A-8: Focusing ultrasound wave (www.nextbigfuture.com).
Linear array transducers require a relatively large area of patient contact (Fig. A-9) and
display a rectangular field on the monitor (Fig. A-10).
Fig. A-9: Linear transducers

Fig. A-10: Rectangular field of the linear probe, goat's kidney (left) and liver (right).
Mechanical sector probes consist of a small number of rotating transducer crystals,

single fixed crystals with an oscillating mirror, or a single oscillating crystal (Fig. A-11).
These cover the field of view and produce a sector image, on the screen (Fig. A-12). The real-
time sector scanner is named because the beam shape and resulting screen image are sector-
shaped or triangular. The sector angle is commonly 90 degrees, but wider or narrower angles
are available for specific purposes. Mechanical real-time sector scanner sweeps the beam
through the field of view by movement of either a solitary crystal or multiple crystals. The
moving parts of mechanical scanners are subject to wear. Electronic sector scanner steer the
soundbeam through the sector field electronically. They may also be dynamically focused by
firing the transducer crystals in time-delay sequences or phases. These phased-array electronic
scanners are superior to mechanical scanners because they do not have moving parts that are
subject to wear. Mechanical scanners have traditionally produced superior image resolution at
higher ultrasound frequencies, but this difference is rapidely disappearing with improving
phase-array technology. Sector transducers require a small area, and thus facilitate
visualization of some structures inaccessible to the linear array transducer.
Fig. A-11: Mechanical sector probes. (a) three-element rotating transducer bathed in acoustic coupling oil. (b) Single
fixed transducer with oscillating mirror. (c) Single oscillation transducer. t = transducer, m = mirror, p = probe (Goddard,
1995).
Curve-linear probe is an electronic modified probe formsector one, which does

not need for rotating crystals (Fig. A-13).
Fig. A-12: Triangular field of the curve-linear probe, Fig. A-13: Curve-linear probe.
goat's kidney (upper) and liver (lower).
Doppler transducers in pulsed systems usually contain a

single crystal, while for continuous-wave Doppler systems
separate transmitting and receiving crystals are needed.
Duplex Doppler Ultrasonography involves the simultaneous
use of real-time, two-dimensional gray-scale ultrasonography,
and pulsed Doppler ultrasound (Fig. A-14). This combination
allows the sonographer to obtain anatomic information with
real-time imaging and functional information regarding blood
flow with the use of Doppler. Doppler Ultrasonography can be
used to identify structures by the presence or absence of flow
(e.g., dilated bile duct vs. portal veins in the liver). It is also
used to determine the presence of flow when thrombosis is
suspected , ascertain the direction of flow, and document
disturbances associated with disease. Blood flow can be Fig. A-14: Doppler ultrasound machine.
estimated by measuring the velocity with Doppler and

multiplying it by the vessel's cross-sectional area determined by two-dimensional imaging
Modes of Echo Display

There are three echo displays, two of which are used more frequently in clinical
applications in veterinary medicine.
A-mode (amplitude mode) is the least frequently used, but still has special use for
ophthalmic examinations and other applications requiring precise length or depth
measurements. A-mode is the simplest of the three modes. The echo’s origin and amplitude
are displayed as spikes originating from a vertical baseline (Fig. A-15). The transducer is
located at the top of the baseline. Depth is represented by a progression from the top to the
bottom of the baseline. Therefore, the position of the spikes along the baseline represents the
depth at which the echoes originated. The height of the spikes above the baseline represents
the amplitude of returning echoes.
Fig. A-15: A mode display (left) and an example for eye examination, a = cornea spike b=anterior lens spikec = posterior
lens spiked = retinal spikee = orbital spike (www.medical-dictionary.thefreedictionary.com).
B-mode (brightness mode) displays the returning echoes

as dotes whose brightness or gray scale is proportional to the
amplitude of the returned echo and whose position corresponds
to the depth at the echo originated along a single line
(representing the beam’s axis) from the transducer. B-mode,
real time scanning producing the illusion of a live, two-
dimensional image representing a slice through the tissue, the
thickness of which is related to the size of the transducer
element (Fig. A-16). The movement of structures greatly
assists tissue identification, and to some extent function as well
as structure may be studied.
Fig. A-16: B-mode display, camel's
M-mode or TM-mode (motion or time-motion mode) is fetus located at the ventral aspect of
used for echocardiography along with B-mode to evaluate the the uterus, 90 d pregnancy.
heart. M-mode tracings usually record depth on the vertical

axis and time on the horizontal axis. The image is oriented with the transducer at the top. The
single line of B-mode dots, with brightness (gray scale) proportional to echo amplitude, is
swept across a video monitor or recorded on a strip chart recorder. The motion of the dots
(change in the distance of reflecting interface from the transducer) is recorded with respect to
time. The echo-tracing produced with M-mode are useful for precise cardiac chamber and
wall measurements and quantitative evaluation of valve or wall motion with time. M-mode
scanning allows the motion of tissues, principally the heart, to be studied by creating a one-
dimensional image that is displayed on the vertical axis with time on the horizontal axis. This
images is rapidly updated (Fig. A-17).
Fig. A-17: M-mode display (right) of fetal heart of a goat (left), 4 months pregnancy.
Doppler ultrasound, often employed for studies of haemodynamics and pregnancy

diagnosis, registers the increase or decrease in frequency caused by structures moving,
respectively, towards or away from the transducer. These differences may be displayed in a
variety of ways including audio and duplex system, the latter of which overlay Doppler
information on a convential two-dimensional, real-time display. Some information can be
displayed with the benefit of colour flow enhancement Fig. A-18.
Fig. A-17: Doppler display for the blood vessels of the kidney.
Real-time Ultrasonography
Real time refers to the ability to see motion on the displayed ultrasound image. The
older B-mode static scanners, which displayed a single frozen image, have been largely
replaced by real-time scanners. Real-time B-mode scanners display a moving gray-scale
image of cross-sectional anatomy. This is accomplished by sweeping a thin and focused
ultrasound beam across a triangular or rectangular field of view in the patient many times per
second. The field is made up of many single B-mode lines. Sound pulses are sent out and
echoes received back sequentially along each B-mode line of the field until a complete sector
or rectangular image is formed. Each line persists on the display monitor until it is renewed
by a subsequent sweep of the beam. Sagittal, transverse, dorsal, or oblique planes through the
body may be obtained by changing the transducer's orientation. Two basic types of real-time
B-mode scanners are available: sector and linear array.
Tissue–Ultrasound waves interaction

The strength of the reflected ultrasound beam depends upon a number of factors, but of
primary importance are the differences in tissue acoustic impendence it encounters on its
journey, the angle at which it meets tissue boundaries and the distance travelled (Fig. A-18).
If the beam were to pass through a homogenous structure then there would be no reflection.
However, even relatively homogenous tissues, such as the liver, present a matrix of small
structural and density variations, and consequently an image of apparently uniform brightness
is produced. At tissue interfaces the density gradient may be marked (a large acoustic
impendence difference) and from such areas a strong echo is generated (e.g. soft tissue / air
interface). Although tissues of similar acoustic density are not themselves easily
differentiated, serosal surface often provide strong lines of demarcation. These acoustically
reflective surfaces normal to the ultrasound beam are termed specular reflectors. Scatter
occurs when the beam meets very small objects or irregular interfaces. As the wavelength
decreases, this effect increases. This type of scatter may provide a measure of tissue quality.
The size of these small scatters aids an important determinant of tissue echogenicity. For
example, the abnormal structure within organs caused by tumor growth may lead to atypical
echogenicity and hence be visible sonographically. The angle at which the beam strikes an
acoustically reflective surface is important, since if the beam is perpendicular to this surface
then much of the reflection is recaptured by the transducer. As the angle is altered less of the
beam is reflected to the transducer. The reflected beam is not available for further tissue
penetration. An ultrasound shadow may be cast if a high percentage of beam energy is lost at
an interface.
Fig. (A-18): Major interactions of the ultrasound beam: (a) when the beam meets a highly reflective surface perpendicular
to it, much is reflected and not available for further tissue penetration. Both echoes return to the probe. (b) If the
angle of incidence is not perpendicular then the reflected signal is not available for recapture. The beam, passing
deeper into the tissue, may be refracted if the tissues are of different acoustical density. Only echo 2 is received by
the probe (Goddard, 1995).
The velocity of ultrasound in tissue varies with tissue density between around 1500 and
1600 m s-1. If the ultrasound beam is subjected to a velocity change across a tissue boundary
at angles other than perpendicular, reflection of the beam may occur. This leads to the
potential for mislocation of structure on the display.
Useful beam is lost from the beam in a variety of ways and the beam is attenuated as it
passes deeper into tissue. As described above, reflection is the chief reason of why the beam
does not penetrate further into tissue. Also as noted above, scatter is responsible for some loss
of beam energy by dispersing the ultrasound beam. This dispersion also has the effect of
spreading the beam, and so it reduces lateral resolution. Passage through a gas-filled structure
(e.g. lung or bowel) also attenuates the beam due to scatter and absorption and will have a
masking effect on more deeply situated structures. Thus cardiac examination must be made at
sides where the heart is not masked by the lung or the ribs. As it travels beyond its focal
length divergence occurs and the beam loses intensity (geometric attenuation).
Attenuation of the Soundbeam

The ultrasoundbeam is attenuated as it travels through tissues toward a reflecting
interface. Echoes reflected back toward the transducer are also attenuated in a similar manner.
The amount of attenuation is directly proportional to the frequency of the beam, with higher
frequencies attenuated much more than lower frequencies in a given medium. Factors that
contribute to attenuation are absorption, reflection, and scattering of the soundbeam. Dark
areas (shadowing) are noted distal to highly attenuating structures, whereas lighter areas
(enhancement) are seen distal to tissues with low sound attenuation.
Absorption refers to conversion of a sound pulse's mechanical energy to heat. This is
primarily due to frictional forces as the molecules of the transmitting medium move back and
forth in a longitudinal manner in response to the passage of a sound wave. Heat production
within tissues is important when the biological effects and safety of ultrasound are considered
the echoes reflected from soft tissue interfaces toward the transducer. The velocity of
ultrasound within each tissue and the tissue density determine the percentage of the beam
reflected or transmitted as it passes from one tissue to another (Table A-1). The product of
tissue's density and the sound velocity within the tissue is known as the tissue's acoustic
impendence. Acoustic impendence is used to refer to the reflection or transmission
characteristic of a tissue. There are only small differences in acoustic impendence among the
body soft tissue. Bone and gas have a very high and low acoustic impendence, respectively.
Air is less dense and more compressible than soft tissue and transmits sound at a lower
velocity. Bone is denser and less compressible than soft tissue and transmits sound at a higher
velocity. This means that when the soundbeam encounters a soft tissue-bone or soft tissue-gas
interface, nearly all sound is reflected and little will be available for imaging deeper
structures. This effect represents a high acoustic impendence mismatch. Distal acoustic
shadowing is produced deep to the bone or gas because of little sound penetrates. Increasing
output intensity will not improve penetration, but merely increases artifacts such as
reverberation echoes. The sonographer must find an acoustic window that avoids bone or gas
when imaging of the abdomen. For the same reason, an acoustic coupling gel is used between
the transducer and the skin for all ultrasound examinations to eliminate interposed air.
Interfaces that are large relative to beam size are known as specular reflectors. Interfaces that
reflect sound away from the transducer do not contribute to image formation. Therefore,
scanning from different angles may improve image quality as different interfaces become
perpendicular to the beam.
Table A-1: Ultrasound reflection at different interfaces

Interface Reflection
Blood-brain 0.3
Kidney-liver 0.6
Blood-kidney 0.7
Liver-muscle 1.8
Blood-fat 10
Muscle-fat 10
Muscle-bone 64.6
Brain-bone 66.1
Water-bone 68.6
Soft tissue-gas 99
When the ultrasound beam encounters small, uneven interfaces in the parenchyma of
organs, scattering occurs. This is also termed diffuse or nonspecular reflection and is
independent of beam angle. Impedance mismatches are small when compared to specular
reflectors, and the returned weak echoes can be imaged only because they are abundant and
tend to reinforce one another. These echoes contribute to the parenchymal texture seen in
abdominal organs, but must not represent actual anatomy.
The velocity change occurring as a sound wave passes from one medium to another
causes the beam to bend if the interface between the medium is struck at an oblique angle.
This can produce an artifact of improper location for an imaged structure. Altering the beam's
direction is called refraction. Refraction along with reflection also contributes to a thin, echo-
poor area lateral and distal to curved structures such as the gallbladder.
Imaging Artifacts
Understanding of the physical properties of sound and various artifacts is essential to
optimize the diagnostic value of ultrasound images. Artifacts can be divided into two
categories. (1) Useless artifacts which produced by improper use of equipment, improper
machine setting, improper scanning producers, or improper patient preparation. These
artifacts usually affect the quality of the images and therefore the interpretation. Useful
artifacts enhance accurate interpretation and are produced under proper technical conditions.
(2) The useful artifacts which resulted from an interactions between ultrasound and matter.
Artifacts may mislead the sonographer, since they are representations on the screen of the
structures that do not exist in the place shown. They may arise from effects within the
instruments or from the use of electrical equipment nearby, or be due to tissue effects. They
may also depend on the technique of the sonographer. If the gain is too great, spurious
reflection may be seen from homogenous structures. If the time-gain compensation does not
truly represent the tissue attenuation, deeper tissues will be misread. Poor patient contact
results in poor transmission of ultrasound, while excessive pressure may distort anatomical
relationship.
Reverberation refers to the production of spurious echoes due to two or more reflectors
in the sound path. The first reflector is usually the skin-transducer interface (external
reverberation). Internal reflectors such as bone or gas are also common causes of
reverberation (internal reverberation), (Fig. A-19). Classic examples of this artifact are the
internal echoes created by superficially located gas-filled bowel segments and the contact
artifact created by interposition of a highly reflective interface (air) between the probe and the
patient (Fig. A-20). This artifact is described in equine thoracic ultrasonography, it is seen on
real time as numerous parallel lines, sliding smoothly along the parietal pleura. Reverberation
artifacts are commonly seen when highly reflective surfaces bounce reflected signals back
into the patient, causing second- and higher-order copies of the true structures to appear at
increasing depth, but with decreasing intensity, on the scanner display. Such effects may be
seen when the ultrasound beam impinges upon the bladder wall or gas in the lumen of the gut.
Within-organ reverberation may also occur. Reverberation echoes may be seen close to
the top of the display if initial transmission from the probe to the patient is poor.
Fig. A-19: Reverberation artifacts Fig. A-20: Reverberations due to bowel gas.
Error in interpreting the location of an organ or structure can occur when a large
reflector such as the diaphragm-lung interface is encountered. In these conditions, the most
common artifact is the mirror-image artifact, (Fig. A-21). This artifact may simulate a
diaphragmatic hernia or lung consolidation. Mirror-image artifacts are produced by rounded
and strongly reflective interfaces such as the diaphragm-lung interface. Part of the insinuating
beam is reflected back into the liver. The echoes from the liver return to the transducer along
the same path, via the diaphragm-lung interface (Fig. A-22). The sound machine assumes that
the sound pulse and the reflected echoes travel to and from the transducer in a straight line. If
the echo return time is delayed because of multiple reflections, the machine places echoes of
more superficial structures at deeper locations (cranial to diaphragm) along the beam's axis. A
mirror image is produced in this erroneous position because of the increased round-trip time.
Fig. A-21: Mirror artifact. Fig. A-22: Hepatic cyst is mirrored on the opposite side of
the diaphragm.
In the bladder and gallbladder, a variant of the side-lobe artifact is the slice-thickness
artifact, which mimics the presence of sediment in the gallbladder or bladder (pseudo-sluge),
(Fig. A-23). This artifact occurs when part of the ultrasound beam's width (thickness) is
outside a cystic structure. Echoes originating from this part of the beam are erroneously
disappearing within the cystic structure on the image. The echoes disappear when the entire
width of the beam is placed within the cystic structure. There are ways to differentiate this
artifact from true sediment. True sediment usually has a flat interface, whereas the surface of
pseduosediment is curved.
Fig. A-23: slice-thickness artifact, pseduosediment at the base of the bladder.

Refraction of the soundbeam occurs when the incident sound wave traverses tissues of
different acoustic impendence. The sound wave transmitted to the second medium changes
direction. This may cause a reflector (e.g. an organ) to be improperly displayed. Numerous in
vivo refraction artifacts such as ghost artifact and organ duplication have been described (Fig.
A-24). Ghost artifact – also called double image artifact- is a common artifact in pelvic
examination. The refraction error appears as a double image. It also occurs when fat
intervenes between the transducer and the target object, due to its low transmission velocity
(Fig. A-25).
Fig. A-24: Ghost artifact. Fig. A-25: Ghost artifact, Single gestational sac –
duplicated, Second copy of the reflector, which is side-by-
side at the same depth as the true reflector.
Acoustic shadowing appears as an area of low-amplitude echoes (hypoechoic-to-
anechoic) created by structures of high attenuation. Acoustic shadowing occurs as a result of
nearly complete reflection or absorption of the sound (Fig. A-26). In the case of a soft tissue-
gas interface, 99% of the sound is reflected and the resulting shadow appears dirty
(inhomogenous) due to multiple reflection or reverberations, or both. In the case of a soft
tissue-bone interface, approximately two thirds of the sound is reflected and a significant
portion absorbed. Therefore there is complete absence of reverberations, and a clean
(uniformly black) shadow is created. Urinary calculi and gallstones tend to behave similarly
to bone and create a strong and clean acoustic shadow. Objects distal to this can only be seen
by altering the angle of the incident beam. Gas in the lumen of the gut, calcified structures or
very dense objects is primarily responsible. Shadows due to refraction by the edges of
rounded objects may also arise. An acoustic shadow is occasionally seen distal to the lateral
margin of cystic structures. This refraction occurring at the margins of rounded structures is
also called edge-shadowing, (Fig. A-27). This artifact is regularly seen at the edges of a
rounded structure such as the bladder, gallbladder, and kidney.
Fig. A-26: Acoustic shadowing in cow' fetus at thoracic Fig. A-27: Edge shadow due to defocusing of the sound
region created by the fetal vertebrae that prevent the beam.
ultrasound waves to pass through it.
Acoustic enhancement (also called through-transmission) represents a localized

increase of echo amplitude occurring distal to a structure of low attenuation. On an ultrasound
scan, enhancement appears as an area of increased brightness; this is commonly seen distal to
the gallbladder, the urinary bladder, and the ovarian follicles (Fig. A-28). This artifact is
helpful in differentiating cystic structures from solid hypoechoic masses. Cysts often have
smooth discrete borders, while abscesses, granuloma, and tumors usually have irregular, ill-
defined borders, whose forms also assist in differentiating different types of masses.
Fig. A-28: Acoustic enhancement distal to a mare ovarian follicle in estrus.
Comet Tail is a series of echoes created by multiple reflections within a small but
highly reflective object; it occurs due to acoustic mismatch (Fig. A-29). The greater the
mismatch the greater the likelihood of comet tail formation. It is a single long hyperechoic
echo that is located in parallel to the sound beam’s main axis (Fig. A-30). It may arise from
the near wall of the gallbladder when crystalline deposits are present. Surgical clips, staples,
sutures and mechanical heart valves are sources for comet tail artifact.
Fig. A-29: Internal reflections give rise to multiple echoes Fig. A-30: Comet Tail artifact, St. Jude valve in open
from an object position
Ringdown (Resonance) is similar to comet tail artifact. It occurs due to the resonance
(vibration) of gas bubbles after being bombarded with ultrasound (Fig. A-31).
Fig. A-31: Ringdown artifact
Suggested Readings
1. Ali A (2000). Principals and clinical applications of the ultrasonography in the field of animal
reproduction. Lecture in the 9th scientific congress of vet. med. 19-20 November, Assiut.
2. Ali A (2001). Ultrasonography as a diagnostic tool in the bovine practice. Lecturer, sixth scientific
congress of cattle diseases, 4-6 November, Assiut.
3. Bhargava SK (2003). Principles and Practice of Ultrasonography, Alpha Science, Amazon.com.
4. Blond L, Buczinski, S (2009). Basis of ultrasound Imaging and the Main Artifacts in Bovine Medicine.
Vet Clin Food Anim 25, 553–565.
5. Braun U (1997). Atlas und lehrbuch der ultraschalldiagnostik beim rind. Berlin: Parey Buchverlag.
6. Cartee RE, Selcer BA . Hudson JA (1995). Practical Veterinary Ultrasound. Lippincott Williams &
Wilkins.
7. Fraser AF, Nagaratnam V, Callicott RB (1971). The comprehensive use of Doppler ultrasound in farm
animal reproduction. Vet Rec 88, 202–205.
8. Goddard PJ (1995). Veterinary Ultrasonography, 1st edition. CABI, Amazon. com.
9. Herring DS, Bjornton G (1985). Physics, facts, and artifacts of diagnostic ultrasound. Vet Clin North Am
Small Anim Pract 15, 1107–1121.
10. Kahn W (2004). Veterinary Reproductive Ultrasonography. Schlutersche, Hannover, Germany.

11. Park R, Nyland T, Lattimer G, Miller C, Lebel J (2005). B-mode gray-scale ultrasound: imaging artifacts
and interpretation principles. Vet Rad Ultras, 22, 204–210.
12. Tempkin BB (2009). Ultrasound Scanning: Principles and Protocols, 3rd Edition, Saunders, MISSOURI,
USA
13. Whittaker AD, Park, B, Thane, BR, Miller, RK, Savell, JW (1992). Principles of ultrasound and
measurement of intramuscular fat. J Anim Sci, 70, 942-952.
14. Yoshinori Y, Kimehiko T (1984). Diagnostic ultrasound imaging in domestic animals: fundamental
studies on abdominal organs and fetuses. Jpn J Vet Sci 46, 203-212.
Part II
Ultrasonography and Veterinary Internal Medicine
By
Mohamed Tharwat (BVSc, MVSc, PhD-Japan)
Chapter 1: Ultrasonography of the Cardiovascular System
Introduction
 Ultrasonography can be of tremendous value in early detection and management of
cardiovascular disease in animals. In most cases, cardiovascular ultrasonography permits
an antemortem diagnosis that can be useful especially in cases with a poor prognosis to
avoid ineffective treatment and to reduce animal suffering.
 Early diagnosis can also be helpful in highly valuable animals by allowing earlier
therapeutic attempts and in monitoring the healing process.
 Diagnosis of heart diseases is challenging because clinical signs can be hidden until signs
of congestive heart failure occur. An early diagnosis is of primary importance because the
prognosis of the most common heart disorders ranges from guarded to poor.
 Conventional methods, such as complete blood cell count and serum biochemistry panel
may lack the sensitivity and specificity to detect heart diseases. In contrast, the main
diseases of superficial vessels may be detected with a precautionary clinical examination;
however, a precise diagnosis requires medical imaging to observe the suspected vessel
and its content.
 Medical imaging is also required for the assessment of deep vessels that cannot be
clinically assessed. For all these reasons, cardiovascular ultrasonography may be valuable
in the diagnosis of suspected cardiovascular disease. With the improvement of ultrasound
equipment quality and portability, these conventional methods can be used in a farm
setting, or in veterinary clinics.
Imaging Technique
 Thoracic radiography is an excellent method for assessing the size and shape of the
cardiac silhouette as well as for evaluating the pulmonary and great vessels, the opacity
and structure of the lung, and the pleural space. Evaluation of the internal architecture and
function of the heart using radiography is only possible through invasive contrast
procedures.
 Imaging of the heart (echocardiography), on the other hand, provides this information
accurately and non-invasively. Two-dimensional (2-D) echocardiography produces real-
time and cross-sectional images of the heart and great vessels, and allows differentiation
of the blood-filled lumen from the soft tissue structures of the heart chambers, valves and
vessels. Motion-mode (M-mode) imaging allows quantitative analysis of the dimensions
and the motion of chambers and valves.
 Doppler analysis provides information on the dynamics of the blood flow through the
heart chambers, along the vessels, and across the valves. A thorough cardiovascular
23
examination does not rely solely on echocardiography, but it includes a detailed physical
examination as well as survey radiography and electrocardiography.
 Ultrasound machines and transducers designed for echocardiography, allow 2-D (B-
mode), M-mode and Doppler examination. Ideally, electrocardiography and Doppler
examination, preferably both colour and spectral, are available as concurrent features and
most support duplex (or triplex) imaging.
 Accurate evaluation of the internal architecture and function of the heart.
 Narrow rib intercostal spaces and lung surrounding the heart result in relatively small
acoustic windows. The ideal transducer therefore should have a small footprint, allowing
coupling of the transducer between ribs and producing a wedge-shaped beam, which fans
out from the thoracic wall. Sector or phased array transducers are therefore the
recommended choice for cardiac sonography. The frequency of the transducer depends on
the size of the animal and the type of examination (3.5 to 7.5 MHz).
 In most cases, the echocardiographic examination is performed without sedation. In
uncooperative animal, where sedation is required, it should be remembered that most
drugs have potential effects on heart rate, contractility, and size. This must be considered
during interpretation.
 Normally, an area of hair, 15x15 cm, over the third, fourth, and fifth intercostal spaces in
the cardiac region is clipped on both sides of the thorax. The region is cleaned with 70 %
alcohol and covered with coupling gel. The heart is then examined ultrasonographically
on the right and then the left sides.
Echocardiography
 2-D echocardiography produces real-time and cross-sectional images of the heart and
great vessels. These images are relatively easy to interpret because they are similar to
anatomical sections through the heart. The images obtained depend on the location of the
transducer over the heart and the orientation of the beam plane.
 M-mode echocardiography utilizes a single thin ultrasound beam rather than a fan-shaped
beam, and is used to record and analyze thickness and motion of the soft tissue structures
of the heart (heart chamber walls, valves and vessels). The distance of individual
structures from the transducer is displayed on the vertical axis and time is displayed on the
horizontal axis. M-mode examinations are carried out almost exclusively from the right
parasternal approaches.
 Because most ultrasound machines allow simultaneous recording of B and M-mode
images, placement of the ultrasound beam is made easier by using the real-time 2-D
image for orientation (Fig. B-1).
Ultrasonography and Veterinary Internal Medicine 25
Fig. B-1. B-M mode images obtained from both the right (a) and left (b) hemithorax. Ds, dorsal; Vt, ventral; IVS, interventricular
septum; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right ventricle; TV, tricuspid valve.
 Recognition of specific structures and interpretation is based on a standardized imaging

technique, knowledge of the anatomy of the heart and standardized measurements.
Echocardiography is always performed in combination with electrocardiography (ECG)
allowing quantitative analysis of measured dimensions, motion, and velocities in a
standardized way.
 Echocardiography can be performed in the field as well as in the clinic. The equipment
required consists of a low-frequency probe (2.5–3.5 MHz) in adults or a higher frequency
probe (3.5–5 MHz) in neonates. The narrow intercostal space, the cranial position of the
heart in the chest, and the shape of the probe may be limiting factors for performing all the
scanning views of the heart. A small phased array (pencil-like) probe is preferred, if
available (Fig. B-2). However, a large sector probe may be sufficient to allow the
diagnosis of endocarditis, pericarditis, and ventricular septal defects, which are considered
the most common cardiac diseases in farm animals.
 Low frequency probes are utilized in cattle where high frequency probes are used in foals
and calves.
Fig. B-2. 1: 3.5 MHz curvilinear probe; 2: 5.0 MHz linear probe; 3: 5.0 MHz endorectal probe; 4: 7.5 MHz endorectal probe.
 In large animals, echocardiography is performed while the animals are standing. On the
other hand, scanning is carried out in small animals while the animal is restrained in a
right lateral recumbency on a special designed table.
 The area from the third to the fifth intercostal space in the cardiac region is clipped and
shaved on both sides of the thorax.
 The skin is then rinsed with warm water or 7% alcohol and transmission gel is applied.
The thoracic limbs can be moved cranially or gently abducted to facilitate better contact
between the probe and the intercostal space.
Normal Echocardiographic Examination
A. Caudal long cardiac axis (right side)
a) Four chamber view

 For obtaining a 4-chamber view, the transducer is placed in the 4th intercostal space, 8-10
cm dorsal to the level of the olecranon. The probe is held parallel to the ribs and directed
slightly craniodorsally (Fig. B-3).
Fig. B-3 Right parasternal caudal long-axis view of the left and right ventricles (four-chamber view) in a camel. The chordae
tendinae of the tricuspid valve are also seen as echoic lines (arrow). Ds, dorsal; Vt, ventral; IVS, interventricular septum;
LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right ventricle; TV, tricuspid valve; CT,
chordae tendinae.
b) Left ventricular outflow tract (LVOT)

 To image the LVOT, consisting of the aortic valve and ascending aorta, the transducer is
positioned as for the 4-chamber view, but turned slightly cranially and rotated 10-40º
clockwise (Fig. B-4).
Fig. B-4. Right parasternal caudal long-axis view of the left ventricular outflow tract in a camel showing both ventricles and
interventricular septum together with the aorta and the aortic valve. Ds, dorsal; Vt, ventral; Ao, aorta; Av, aortic valve; IVS,
interventricular septum; LA, left atrium; LV, left ventricle; RV, right ventricle.
B. Caudal short axis view of the heart (right side)

 The probe is placed in the 4th intercostal space, 3-6 cm dorsal to the level of the olecranon,
and held at right angles to the ribs and tipped slightly dorsally (Fig. B-5).
Fig. B-5. Right short-axis view of the cardiac ventricles in a camel. Both ventricles are seen in a transverse section. Ds, dorsal;
Vt, ventral; RVW, right ventricular wall; RV, right ventricle; IVS, interventricular septum; LV, left ventricle.
C. Cranial long axis view of the heart (right side)

 To image the right ventricular outflow tract (RVOT), consisting of the pulmonary artery
and valve, from the right side, the transducer is held parallel to the ribs in the 3rd
intercostal space, 8-10 cm dorsal to the level of the olecranon (Fig. B-6).
Fig. B-6. Right parasternal caudal long-axis view showing the four-chamber view together with the left ventricular outflow tract view
in a camel. The chordae tendinae of the mitral valve are also seen as echoic lines Ds, dorsal; Vt, ventral; Ao, aorta; Av, aortic
valve; IVS, interventricular septum; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RV, right
ventricle; TV, tricuspid valve; CT, chordae tendinae; PM, papillary muscles.
D. Caudal long axis view of the heart (left side)

 This image reveals the right and left ventricular outflow tract.
a) Two chamber view

 To image the left and right ventricles, the transducer is held parallel to the ribs in the 4th
intercostal space, 5-10 cm dorsal to the level of the olecranon, and turned slightly
caudodorsally (Fig. B-7).
Fig. B-7. Left parasternal caudal long-axis view of the hear in a camel. In this view, the four cardiac chambers are observed as well as
the atrioventricular valves. Ds, dorsal; Vt, ventral; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium;
RV, right ventricle; TV, tricuspid valve; IVS, interventricular septum.
b) Left ventricular outflow tract

 To image the LVOT, consisting of the aortic valve and ascending aorta, the transducer is
first positioned as described for the view of the left and right ventricles on the left side, but
is turned slightly cranially and rotated 10º anticlockwise (Fig. B-8).
Fig. B-8. Left parasternal caudal long-axis view of the left ventricular outflow tract in a camel. The left ventricle and aorta are observed. The
transversa view of the aortic valve is recognized as a thin echoic line. Ds, dorsal; Vt, ventral; RV, right ventricle; LV, left ventricle;
RA, right atrium; IVS, interventricular septum, Ao, aorta; AV, aortic valve; Oc, ossa chordis.
E. Cranial long axis view of the heart (left side)

 In the cranial long axis view of the heart, the RVOT, consisting of the pulmonary artery
and valve are imaged. The probe is held parallel to the ribs in the 3rd intercostal space on
the left, 3-6 cm dorsal to the level of the olecranon, and turned slightly craniodorsally
(Fig. B-9).
Fig. B-9. Left parasternal cranial long-axis view of the right ventricular outflow tract in a camel. The left ventricle and aorta are
observed. The transversa view of the aortic valve is recognized as a thin echoic line. Ds, dorsal; Vt, ventral; RV, right ventricle;
RA, right atrium; TV, tricuspid valve; Ao, aorta; PA, pulmonary artery; PV, pulmonary valve.
Practical Application of Echocardiography

 Although the clinical manifestations of heart disease may be indicative of most cardiac
disorders, the definitive diagnosis requires ancillary tests, such as serum biochemistry
panel, complete cell blood count, blood culture, pericardiocentesis, electrocardiography,
and echocardiography.
 Echocardiography is a noninvasive diagnostic imaging technique that permits immediate
diagnosis, which can be useful in a field setting when clinical signs are not obvious or
with commercial animals to allow rapid culling or euthanasia if the diagnosis and the
associated prognosis are not compatible with financial restraints or animal welfare.
 The echocardiographic findings in cases of suspected heart disease include specific and
non-specific cardiac findings. The non-specific findings appear secondary to congestive
heart failure (e.g., pleural effusion, compression of the lung). The most common cardiac
diseases such as pericarditis, infectious endocarditis, and ventricular septal defects can be
suspected on the basis of clinical findings and echocardiographic findings.
Congenital Heart Disease

 Many specific congenital defects are suspected from physical examination of the animal,
radiographs survey of the thorax and ECG tracings. However, echocardiography remains
the only non-invasive method to definitively diagnose a specific lesion and quantify the
severity of the cardiac change.
 Most congenital heart diseases are based on specific anatomical defects, which can be
directly demonstrated by ultrasonography. In other cases, the compensatory dilatation or
hypertrophy may suggest a specific lesion.
 Together with the physical examination and radiography, not only the type of defect, but
also the severity of the disease can be evaluated.
 Because many congenital diseases have a hereditary background, breeding programmes
are also often based on the results of an echocardiographic examination. The following are
the most common congenital heart defects.
Ventricular Septal Defect (VSD)

 Ventricular septal defects (VSDs) consist of a single opening in the upper ventricular
septum just below the aortic valve (subaortic). VSDs are relatively common and occur
mostly in combination with other cardiac defects.
 A VSD usually results in a left-to-right shunt predominantly during systole with quick
ejection of the blood into the pulmonic artery, thus sparing the right ventricle from volume
overload.
 In large VSDs, right ventricular overload and dilatation of the right ventricle, left atrium
and left ventricle will occur.
 2-D echocardiography using the right parasternal long- or short-axis plane usually will
demonstrate the typical subaortic defects. The typical features include left ventricular
overload, a hyperdynamic left ventricle, and a dilatation of the left atrium.
 An experienced sonographer will detect nearly 100% of VSDs and will also gain
information on the magnitude of a shunt. Location and direction of a shunt can be
determined best by using color Doppler technique; the high velocity and turbulent systolic
jet can be quantified using continuous-wave Doppler (Fig. B-10).
Tetralogy of Fallot
 Tetralogy of Fallot (TOF) is an encountered complex malformation and consists of VSD,
pulmonic stenosis (PS), right ventricular hypertrophy, and dextraposition (overriding) of
the aorta (Fig. B-10).
 VSD and PS are pathophysiologically important, leading to right ventricular hypertrophy
and in cases with severe pulmonic stenosis to a right-to-left shunt. The typical features of
2-D echocardiography from the right parasternal locations include concentric hypertrophy
of the right ventricle, the usually large VSD and the overriding aorta.
 It is important to evaluate the pulmonic valve (TOF typically has valvular stenosis) and
main PA allowing differentiation of TOF with persistent truncus arteriosus (no separate
PA) and Eisenmenger’s syndrome (right-to-left shunt without pulmonic stenosis).
 M-mode echocardiography is especially helpful in assessing the concentric hypertrophy,
but fails to demonstrate all the features of a TOF.
Eisenmenger’s Syndrome
 Eisenmenger’s syndrome, a communication between the right and the left side of the heart
(at the level of the atria, ventricular septum (VS) or great vessels), pulmonary
hypertension and right-to-left shunt and many other malformations.
 Most of them can be diagnosed correctly by a skilled cardiologist using echocardiography,
but some may also require cardiac catheterization and contrast studies.
Fig. B-10. Two-dimensional echocardiogram of a calf with Tetralogy of Fallot. A: A cranial long-axis view of the heart taken from
the right thorax. The image, taken during systole, demonstrates a dilated right atrium (RA). B: A caudal long-axis view of
the heart scanned from the left thorax. A large ventricular septal defect (VSD) is seen between the right ventricle (RV) and
the left ventricle (LV), at the top of the interventricular septum (IVS), and the aorta (Ao) overrides both ventricles. The
image was taken during systole. Note that the aorta receives blood from both ventricles
Acquired heart disease

 The echocardiographic examination of acquired heart disease follows the same principles
as for congenital heart defects. The first step is to recognize secondary abnormalities such
as dilatation or hypertrophy of heart chambers. Second, identification of the primary
lesion is important and third, comparison of the echocardiographic findings with the
clinical examination, ECG, and radiographs. Finally, degenerative and infective valvular
disease, myocardial and pericardial diseases are described.
Bacterial Endocarditis and Endocardial Diseases

 Bacterial endocarditis is the most common endocardial disease in cattle. The infection
most frequently involves the valvular endocardium, leading to a thickened endocardium
and valvular insufficiency.
 Clinical diagnosis of bacterial endocarditis may be difficult in the absence of heart
murmur and clinical signs of heart failure. Cardiac auscultation reveals a murmur
secondary to valvular insufficiency in 50% to 80% of cases. Clinical signs of heart failure
are not definitive in cattle. The auscultation of a cardiac murmur may be heard in cases of
congenital heart disease and even in healthy cattle, in addition to cases of bacterial
endocarditis.
 Echocardiography is a sensitive diagnostic tool for cases of endocarditis. The tricuspid
valve is the valve most frequently affected by bacterial endocarditis. The infection of more
than one valve may occur in 13% to 53% of cases. The mural endocardium may rarely be
affected.
 Compared to controls (Fig. B-11), typical echocardiographic findings in cases of bacterial
endocarditis include a marked irregular thickening of the affected valvular leaflet or of the
mural endocardium that can confer vegetation or a ‘‘shaggy’’ appearance (Fig. B-12, B-
13 & B-14).
 All heart valves should be properly imaged. The infected endocardium is more frequently
echogenic than hyperechoic with gaseous content. When valvular thickening is observed,
bacterial endocarditis should be the first diagnosis on the differential list. Secondary to the
valvular deformation, regurgitant lesions leading to cardiac chamber dilation may also
occur. The right atrium and right ventricle may enlarge secondary to tricuspid
endocarditis.
 Although information is still lacking in cattle, echocardiography has been mentioned as a
beneficial ancillary tool to monitor the valvular healing of equine endocarditis. During the
healing process, the lesions tend to be smaller, smoother, and more echoic.
Echocardiography could potentially be useful in bovine cases in which therapy is
attempted.
Fig. B-11. Ultrasonograms of the normal pulmonary valve (A; closed valve during diastole, arrow and B; open valve during systole,
arrow). In C, the pulmonary valve is transversely imaged over the aorta in healthy animals.
 Bacterial infection caused by septic thrombi affects mainly the mitral valve and/or aortic
valve, rarely the tricuspid valve and pulmonic valve. Infective endocarditis causes
insufficiency of the affected valves, left ventricular overload, and left heart failure. 2-D
echocardiography readily identifies the shaggy appearance or the hyperechoic irregular
vegetations.
 The ultrasonographic findings in endocarditis are the presence of echoes from an adherent
mass on the valvular leaflets. These echoes are observed as systole and diastole.
Additional evidence of cardiac disease and its consequences can be assessed by measuring
cardiac chamber diameters, ventricular wall thickness, and ventricular wall motion, and by
calculating various indexes of cardiac function.
Fig. B-12. Echocardiography of cattle with tricuspid and mitral valve vegetations. A represents a four-chamber view of the heart in a
healthy cow. B shows mitral valve vegetation imaged at the left 5th intercostal space. C to F represents tricuspid valve
vegetation where a highly thickened valve with thrombosis is observed. Image was taken using a 3.5 MHz linear transducer.
T, tricuspid valve; M, mitral valve; RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; TV, tricuspid
valve; IVS, interventricular septum; TV Veg, tricuspid valve vegetation; RVO, right ventricular outflow. LVW, left
ventricular wall; RVW, right ventricular wall; T, thrombus; M, mitral valve; RA, right atrium; LA, left atrium; RV, right
ventricle; LV, left ventricle; IVS; interventricular septum, TV Veg; tricuspid valve vegetation; MV Veg, mitral valve
vegetation. Arrows point to tricuspid and mitral valve vegetations.
Fig. B-13. Ultrasonographic imaging of pulmonic valve revealed a highly thickened valve with thrombosis (A, B and C). Image was taken at the
left 3rd intercostal space using a 3.5 MHz linear transducer. PA; pulmonary artery, PULA; pulmonary artery, A; aorta, RVOT, right
ventricular outflow tract, IVS; interventricular septum, LV; left ventricle, T; thrombus. Arrows indicate vegetations.
Fig. B-14. Ultrasonograms of a massive pulmonary thrombosis in 6 cows with pulmonic vegetations. Images were taken at the left 3rd intercostal
space using a 3.5 MHz linear transducer. PA; pulmonary artery, A; aorta, RVOT, right ventricular outflow tract, IVS; interventricular
septum, RV; right ventricle, LV; left ventricle, RVOT, right ventricular outflow tract, Th; thrombus. Arrows indicate thrombosis.
Pericarditis and pericardial effusions
 Ultrasonography is the method of choice for imaging and characterizing pericardial
effusion. Ultrasonographic examination of the normal bovine heart is performed on
standing cows using a 5.0 MHz sector or convex transducer from the 3rd to 5th intercostal
spaces in the cardiac region on both sides of the thorax. Pericarditis is the most common
pericardial disorder in cattle. Pericardial effusion is often secondary to hardware diseases
and consists of a purulent effusion with varying amounts of fibrin clots. Pericardial
effusion should not be confused with bilateral pleuritis in which anomalies of the pleural
space and the lung parenchyma can also be found.
 Pericardial effusion (PE) is the most common pericardial disease. Echocardiography is the
method of choice in differentiating primary heart disease from pericardial effusion and in
searching for the cause of the effusion. The 2-D examination is very sensitive in detecting
even very small amounts of fluid in subclinical cases. Features of pericardial effusion
include a hypo- or anechoic space between the heart wall and pericardial sac. In more
pronounced cases, diminished right ventricle and left ventricle internal dimensions and
swinging of the heart in the fluid-filled pericardial sac during the heart cycle. In cases with
pleural effusion, the pericardium can be outlined. In pericarditis, the pericardium may be
thickened.
 In horses, depending on the clinical and echocardiographic findings, three forms of
pericarditis have been described: the effusive form (leading to cardiac tamponade caused
by pericardial effusion), the fibrinous form (with accumulation of fibrin in the
pericardium), and the constrictive form, in which pericardial thickening reduces the
diastolic filling of the heart. In cattle, this classification does not exist. Pericardial effusion
typically compresses the right ventricle and atrium, and the left ventricle. This
compression is particularly visible during cardiac diastole when measuring the cardiac
chamber dimensions. The end diastolic ventricular volume is reduced secondary to the
increased pericardial pressure, which leads to a decrease in heart preload, and a decreased
cardiac output partially compensated by an increased heart rate at rest. Epicardial deposits
of echogenic fibrin may also be a limiting factor for ventricular diastole as found in cases
of effusive-constrictive pericarditis syndrome in humans.
 Pericardial effusion may also be observed with the occurrence of other cardiac and non-
cardiac diseases. Various heart neoplasms can lead to an anechoic pericardial effusion,
discussed below. Anechoic pericardial effusion can also be seen in cases of
hypoproteinemia, right heart failure, or viral disease in horses. Evidence-based medicine
concerning the clinical impact of echocardiographic findings in cattle with pericardial
effusion is still lacking. Case series demonstrated that, as in horse, echocardiography
could be used to observe the beneficial effects of pericardial drainage and the progression
of pericardial fluid accumulation. However, for the moment, there are no prognostic
echocardiographic factors that can be used by the bovine practitioner. Echocardiography
is useful to confirm the suspicion of pericardial effusion, to observe the impact of
pericardial effusion on the cardiac chambers or function, to differentiate pericardial and
pleural effusion, and to help the clinician choose the optimal site of the pericardiocentesis.
 Ultrasonographic characteristics in cases of traumatic pericarditis include the presence of
large amounts of hypoechogenic fluid presternal (Fig. B-15), distension of the jugular and
milk vein (Fig. B-16) and also in the thorax, sometimes containing strands or free clots of
fibrin (Fig. B-17). The lungs are compressed and displaced medially and dorsally by the
pleural effusion (Fig. B-18). Sometimes the effusion obscures the heart.
 Affected cows usually have a large amount of hypoechogenic to echogenic pericardial
fluid, and echogenic deposits and strands of fibrin may be seen on the epicardium (Fig. B-
19). Sometimes strands of fibrin are seen floating in the fluid between the epicardium and
pericardium. The cardiac ventricles are moderately to severely compressed depending on
the amount of fluid.
Fig. B-16. Ultrasonograms in 2 abuffaloes affected with traumatic pericarditis. Images were taken from the fifth intercostal space on the
left side of the thorax. Fluids in the pericardium are presented as mild (A) or massive anechoic (B) accumulations.
Fig. B-17. Ultrasonograms in 4 abuffaloes affected with fibrinous pericarditis. On the outside of the pericardium, fibrinous layers are
floating in the fluid. Images were taken from the fifth intercostal space on the left side of the thorax. LV, left ventricle; IVS,
interventricular septum.
Fig. B-18. Sonogram of the heart of a cow with fibrinous pericarditis. On the outside of the pericardium, fibrinous layers are floating in
the fluid; LV, left ventricle; LVW, left ventricular wall; MV, mitral valve.
Fig. B-19. Ultrasonograms in 6 abuffaloes affected with suppurative pericarditis. On the outside of the pericardium, fibrinous layers are floating in
the fluid. Images were taken from the fifth intercostal space on the left side of the thorax. Homogenous echogenic pericardial effusions are
seen in A, B, E and F. Heterogeneous pericardial effusions are seen in C and D. LV, left ventricle; RV, right ventricle; IVS, interventricular
septum; P, pericardium.
Practical ultrasonography of the vascular system

 Vascular ultrasonography can be helpful in the noninvasive diagnosis of vascular disease
when clinical signs are insufficient to make a diagnosis and also for deep vessel
assessment.
 Ultrasonography can be used for examination of the jugular, mammary (Fig. B-20),
caudal vena cava, portal vein, hepatic vein (Fig. B-21) and musculophrenic vein (Fig. B-
22). The normal findings of venous ultrasonography include a thin echogenic wall with
anechoic content. The superficial vein diameter and appearance can be affected by how
much pressure is applied to the probe.
Fig. B-20. Ultrasonographic imaging of jugular (A) and milk vein (B) in a buffalo affected with traumatic pericarditis. The distended
jugular vein appears circular, while the distended milk vein appears oval.
Fig. B-21. Ultrasonographic imaging of caudal vena cava (CVC), hepatic vein and portal vein in 3 buffaloes with traumatic pericarditis. The
distended CVC appears circular.
Fig. B-22. Ultrasonographic imaging of the musculophrenic vein (MV) in a cow traumatic reticuloperitonitis. Ret = reticulum.
Chapter 2: Ultrasonography of the Respiratory System
Introduction
 Numerous diagnostic methods are used to evaluate diseases that affect the respiratory
system, including auscultation, percussion, bloodwork, radiography, ultrasonography, and
more invasive procedures such as aspirations and biopsies.
 Ultrasonography is a noninvasive diagnostic tool that has been used for the past several
years in veterinary and human medicine to assess the lungs, the pleura, and the
mediastinum. Ultrasonography of the upper respiratory system has been the subject of
several publications in equine medicine. In ruminants, ultrasonography of the upper
respiratory system is less frequent because of the use of endoscopy; however,
ultrasonography may be useful in the evaluation of masses such as abscesses in the soft
tissue surrounding the larynx and trachea.
 Ultrasonographic examination of the pleura and the lung helps detect various lesions. It
brings accuracy and complements radiography. Some ultrasound images are characteristic
of pathologic processes, and can help clinicians with their diagnosis by allowing
visualization of the lesion itself or serving as a guide for aspiration. This examination
allows evaluation of the extent and severity of pulmonary changes when they are against
the pleura.
 Lesions that are located deeper in the lung tissue are not visible. In current veterinary farm
practice, however, in which radiographic examination is impossible, ultrasonography is a
diagnostic tool that is available, quickly performed, and noninvasive.
 In human medicine, ultrasonography of the lungs is one of the important tools in the
management of critical patients and urgent cases, not only for the detection of pleural
effusion but also for the identification of pneumothorax, alveolar consolidation, and
interstitial syndromes. In ruminants, ultrasonography of the lungs and pleura has been the
subject of several research projects and publications.
 It is particularly useful for the detection and characterization of pleural effusion, especially
small amounts, the detection of superficial pulmonary lesions or consolidation, pulmonary
atelectasia, and pneumothorax. In some cases, an ultrasonographic examination brings
further precision to a radiographic examination. This is particularly true regarding the
cranioventral part of the thorax, as radiographs of this region are more difficult to analyze
because of overlap of the soft tissue, bone, and the cardiac silhouette.
Imaging technique
 Ultrasound examination of the thoracic cavity is hampered by the surrounding bony rib
cage and the air-filled lungs within. However, where an acoustic window can be obtained,
this is an increasingly and widely used technique for assessment of pleural, pulmonary,
and mediastinal disease.
 Perhaps one of the most significant advantages of ultrasound is that fluid and soft tissue
may be distinguished so that effusions secondary to an intrathoracic mass or
diaphragmatic rupture can be distinguished from those of primary origin. Little patient
preparation is required prior to thoracic ultrasound.
 It is useful to remember that the higher frequency produces superior resolution but allows
a shallower area of examination, such that a 10 MHz transducer is useful up to
approximately 4 cm, 7.5 MHz is useful up to approximately 6 cm depth, and a 5 MHz up
to 15 cm depth. Because of the bony ribcage, a sector or a microconvex transducer is
required to allow penetration between the ribs. The hair is clipped on both sides from a
site caudal to the scapula to the last rib, and also from the transverse processes of the
thoracic vertebrae to the elbow. The area is swabbed with alcohol to remove excess oil,
and coupling gel is applied.
Physiological appearance of the lungs and pleura

 Normal lung tissue cannot be shown due to its air content but reverberation artifacts in the
form of echogenic bands running parallel to the surface of the lungs are usually visible.
Costal and pulmonary pleura cannot always be distinguished but they are represented by a
smooth hyperechoic line between the surface of the lungs and the musculature of the
thoracic wall. The motion of the lungs synchronous with respiration is visible with both
high frequency and low frequency transducers. In obese animals, reverberation artifacts
are often not visible despite the presence of physiological lung tissue.
 The normal appearance must be known before the abnormal can be reliably and safely
detected and deciphered. Due to reflection of 99% of the sound beam at the interface of
the lung and soft tissue, it is not possible to image beyond the most superficial layer of
normal lung tissue. Therefore, when the transducer is applied to the intercostal spaces,
with the exception of the acoustic window afforded by the heart, typical reverberation
artefact is seen (Fig. B-23). The heart is generally seen from both the right and left sides
roughly between rib spaces 3 to 7. This is subject to slight individual variation and so; the
apex beat is often used to indicate the most appropriate site.
Fig. B-23. Sonogram of the surface of a normal lung (3.5 MHz): echogenic line (white arrow), visceral and parietal pleura,
echogenic lines running parallel to the pulmonary surface (black arrows), reverberation artifacts.
Ultrasonographic appearance of thoracic pathologies
Pleural lesions
Pleural Effusion
 The sonographic appearance of a pleural effusion varies with the character and volume of
fluid present. Fluids such as transudate are usually totally black with the pleural
reflections seen as fine echogenic lines ‘floating’ in the surrounding fluid (Fig.s B-24, B-
25 and B-26). As the cellular content of the fluid increases it becomes more echogenic and
may even, in some cases, develop an almost granular appearance.
 Occasionally, if the fluid is localized, it may be possible to confuse this with a hypoechoic
mass. When fluid is an exudate or hemorrhage there may be surrounding inflammation so
that the pleural surfaces become thickened and irregular. This is seen on the pleural
reflections and around the pericardium, and may be found with pyothorax.
Fig. B-24. Sonogram of a lung of a cow with moderate pleural effusion (3.5 MHz): the lung with its irregular surface is displaced from
the chest wall by the hypoechoic fluid.
Fig. B-25. Anechoic advanced degree of pleural effusion (transudate) in 2 buffaloes (A and B) and 4 cows (C, D, E and F).
Fig. B-26. Fibrinous pleuritis in a cow. Fibrin septae are apparent stretched, which are distinctly seen to float in real time mode.
Pneumothorax
 A pneumothorax is the result of an accumulation of free air between the visceral and
parietal pleura. Normally, breathing allows the operator to observe the sliding movement
of one pleura along the other. The two pleura are not distinguishable during an ultrasound
examination other than by their movement.
 When a pneumothorax is present, air infiltrates between the two pleura and the sliding
movement is no longer visible. The obtained image is just immobile artifacts of
reverberation (Fig. B-27).
 An ultrasonographic examination of the thorax allows assessment of the extent of the
pneumothorax and facilitates the installation of a thoracic drain as a way of providing
relief to the patient.
Fig. B-27. Sonogram of pneumothorax (3.5 MHz) in a buffalo. Sonogram represents numerous echogenic bands (black arrows) from
the lung surface are comet-tail artifacts; (white arrow), pleura.
Pulmonary lesions
Pulmonary consolidation
 Generally with inflammatory or infectious conditions the lung lobes retain a sharp and
almost triangular appearance. This is seen especially clearly where the lung is surrounded
by pleural fluid. Unfortunately, consolidated lung has an appearance very similar to that of
the liver. Care must be taken to differentiate the two, and to correctly interpret mirror-
image artefact.
 In consolidated lung there are small irregular hyperechoic area, which correspond to small
pockets of remaining gas (Fig. B-28 and B-29). This should help differentiate lung from
liver. It is also useful to remember that mirror-image artefact does not occur in the face of
pleural effusion, and that liver tissue should contain characteristic vessels.
 Pulmonary consolidation may be due to infection, inflammation, granuloma formation or
neoplasia. When assessing an area of consolidated lung tissue, as elsewhere in the body,
there are certain questions to be asked that will help produce a list of differential
diagnoses: what is the echogenicity? is it homogeneous or is it not? and, if not, what
echogenicities are present? what shape is the lobe? and are the changes discrete?
Fig. B-28. Consolidated lung vs. mirror-image artefact. In consolidated lung there are often small pockets of gas remaining, seen as
small hyperechoic areas, which cast an acoustic shadow. The mirror-image artefact does not show these features.
Fig. B-29. Consolidated lung tissue can be difficult to differentiate from mirror-image artefact. In consolidated lung there are often
small pockets of gas remaining, seen as small hyperechoic areas, which cast an acoustic shadow.
Presence of comet-tail artifacts and an interstitial syndrome

 Comet tails are artifacts. In human medicine, however, the presence of numerous comet-
tail artifacts on a single image can indicate an interstitial syndrome.
 Diffuse parenchymal lung disease must be considered if multiple comet-tail artifacts are
distributed over the entire lung surface and are associated with thickened and irregular
pleura.
 In cattle, was also reported that the presence of comet-tail artifacts in the presence of
pulmonary emphysema (Fig. B-30).
Fig. B-30. Sonogram of the lung of a cow with bronchopneumonia (3.5 and 5 MHz, respectively): the small hypoechoic zone on the surface of
the lung represents ‘‘superficial fluid alveologram’’ with comet-tail artifacts.
Pleural abscesses
 There is loss of the white linear echo formed by the visceral or pulmonary pleura, and no
reverberation artifacts are visualized.
 The pleural abscesses appear as uniform hypoechoic areas extending up to 8cm in depth
containing many hyperechoic spots (Fig. B-31 and B-32). The pleural abscesses may be
unilateral or bilateral.
Fig. B-31. Ultrasonogram of 2 cows with pleural abscess. A hypoechoic area can be visualized immediately below the chest wall and bordered
by a broad hyperechoic line.
Fig. B-32. Ultrasonogram of cow with pleural abscess. A hypoechoic area can be visualized immediately below the chest wall and
bordered by a broad hyperechoic line.
Mediastinal abscesses
 Each intercostal space was examined dorsoventrally, with the transducer held parallel to
the ribs. In the thoracic cavity, the lungs, heart and its major blood vessels and the
mediastinal region were also scanned. The thoracic abscesses were all mediastinal or near
the heart.
 All cases were imaged on the left thorax, four in the third and one in the fourth intercostal
space. In three of the animals, the abscess had a well-developed capsule, which appeared
as an echogenic line that demarcated the contents of the abscess from either the heart or
lung. The content of the abscess was echogenic in three animals and anechoic in two.
 The ultrasonographic appearance of the content of the abscess is either homogenous and
had hyperechogenic foci or with echogenic contents and surrounded by a narrow anechoic
rim of fluid (Fig. B-33).
Fig. B-33. Ultrasonogram of intra-thoracic

abscesses imaged at the third (a, b, c)
and fourth (d) intercostals spaces. The
contents appear echogenic and
homogenous in (b), echogenic with
hyperechogenic foci in (a) and (c) and
anechoic in (d). In (b), a rim of fluid
Chapter 3: Ultrasonography of the Digestive System
Introduction
 Ultrasonography and radiography are the techniques that are most commonly used for
imaging the gastro-intestinal tract. However, ultrasonography is an ideal diagnostic tool
for the investigation of gastrointestinal disorders in most animals.
 An ultrasonographic examination is performed on non-sedated animal after the
application of transmission gel. The hair is clipped from the area where the transducer is
to be applied; for optimal transmission of ultrasound waves, remaining hair may be
removed using a depilatory cream.
 The advantages of ultrasound for imaging the gastro-intestinal tract are that it is a non-
invasive procedure, the entire thickness of the bowel wall can be imaged, the intestinal
motility can be assessed in real time and fine-needle aspirate, or the other forms of guided
percutaneous biopsy can be performed.
 Artefact produced by gas normally found in the bowel lumen results in an incomplete
visualization of the wall of the gastro-intestinal tract – a factor that should be taken into
account when aiming to rule out a gastro-intestinal lesion.
 Ultrasonography is an ideal diagnostic tool for the investigation of bovine gastrointestinal
disorders, the most common of which are traumatic reticuloperitonitis, left and right
displacement of the abomasum, ileus of the small intestine, and dilatation and
displacement of the cecum. An ultrasonographic examination is performed on nonsedated,
standing animal using a 3.5 MHz to 5.0 linear or convex transducer.
 When a tentative diagnosis has been made based on the clinical findings, only the region
in question is the examined. For example, in cases with suspected traumatic
reticuloperitonitis, the examination is performed in the sternal and parasternal regions.
 Even experienced clinicians may not be able to pinpoint the organ affected and make a
diagnosis in patients in which abdominal disease is suspected, however. In such cases,
both sides of the abdomen are examined.
 Normally, the reticulum, spleen, rumen, and parts of the abomasum are seen on the left
side; and the omasum, parts of the abomasum, small intestine, large intestine, and right
kidney are seen on the right.
Ultrasonographic examination of the digestive system in ruminants
Normal reticulum
 For ultrasonographic examination of the reticulum, the transducer is applied to the ventral
aspect of the thorax on the left and right of the sternum as well as to the left and right
lateral thorax up to the level of the elbow. The reticulum is first examined from the left
side and then from the right. The normal reticulum appears as a half-moon-shaped
structure with an even contour (Fig. B-34).
 The reticulum contracts at regular intervals and, when relaxed, is situated immediately
adjacent to the diaphragm and ventral portion of the abdominal wall. The different layers
of the reticular wall cannot usually be imaged, and the honeycomb-like structure of the
mucosa is not often seen. Contents of the reticulum cannot be normally imaged because of
their partly gaseous composition. Foreign bodies and magnets also cannot usually be seen
in the reticulum because of the gas content of the reticulum.
 On the left side of the animal, the wall of the craniodorsal blind sac of the rumen, the
ruminoreticular groove, and the wall of the ventral sac of the rumen are seen as echogenic
lines caudal to the reticulum.
Fig. B-34. Ultrasonogram of the normal reticulum viewed from the left ventral thorax. (1) Ventral abdominal wall, (2) musculophrenic
vein, (3) smooth reticulum, (4) craniodorsal blind sac of the rumen, (5) spleen, Cr: cranial and Cd: caudal.
 For an assessment of reticular motility, the transducer is placed over the left ventral
thoracic region. The reticulum is located and observed for 3 min without moving the
transducer.
 The number, amplitude, duration and speed of reticular contractions and the duration of
the interval of relaxation between two biphasic reticular contractions are assessed.
 The reticulum normally contracts once per minute. Thus, in the 3-minobservation period,
the reticulum has three biphasic contractions, the first of which is incomplete. Contraction
of the craniodorsal blind sac of the rumen is frequently seen immediately after the second
reticular contraction. Rumination is associated with an additional ruminal contraction,
which occurs immediately prior to the biphasic contraction.
Ultrasonography of the normal spleen

 In cattle, the abdominal wall, spleen and wall of the rumen or reticulum can usually be
imaged from the sixth and seventh intercostal spaces of the left ventral thorax.
 Ultrasonographically, the spleen appears in cross-section as a 2–3 cm thick structure
situated between the abdominal wall and the rumen or the reticulum. The capsule of the
spleen appears as an echogenic line, and the splenic pulp appears as many small, evenly
distributed echoes. The vasculature of the spleen is seen in cross-section as oval
hypoechogenic structures in the pulp (Fig. B-35).
Fig. B-35. Ultrasonogram of the normal spleen in cattle. A 5.0-MHz linear transducer was placed (A) in the 10th intercostals space, (B)
in the 9th intercostals space and (C) in the left paramedian region parallel to the ventral midline 1 – thoracic wall; 2 – spleen; 3
– spleen vessel in longitudinal section; 4 – rumen, Ds – dorsal; Vt – ventral; Md – medial.
Abnormal appearance
 In cattle with traumatic reticuloperitonitis, ultrasonography can be used to identify
morphological changes in the region of the cranial, ventral, or caudal reticular wall.
 The caudoventral reticular wall is the most frequently affected, often in association with
the craniodorsal blind sac of the rumen. The changes in the contour of the reticulum
depend on the severity of the inflammatory changes (Fig. B-36, B-37, B-38, B-39 and B-
40).
 Reticular activity is almost always affected in cattle with traumatic reticuloperitonitis. The
frequency, amplitude or velocity of contractions, singly or combined, may be abnormal.
 The frequency can be reduced from three to two, one or no contractions per 3 min. The
reduction in the amplitude of contractions varies; when formation of adhesions is
extensive, reticular contractions appear indistinct via ultrasonography.
 Although the pattern of biphasic contraction is often maintained, the reticulum contracts
by only 1–3 cm. The velocity of reticular contractions may be normal, but can be
markedly reduced.
 In cattle with reticulo-omasal obstruction, due to a foreign body, the frequency of reticular
contractions may be increased.
 The spleen, particularly its distal portion, is often affected in cattle with traumatic
reticuloperitonitis.
 Fibrinous changes are frequently seen as echogenic deposits of varying thickness, often
surrounded by fluid, between the spleen and reticulum or rumen. The spleen may be
covered with fibrinous deposits. Occasionally, one or more splenic abscesses are visible,
and the vasculature may be dilated indicating splenitis.
Fig. B-36. Ultrasonogram of the spleen in a cow with traumatic suppurative splenitis
Fig. B-37. Ultrasonogram showing fibrinous adhesions between the reticulum, craniodorsal blind sac of the rumen and spleen of 2
cows with traumatic reticuloperitonitis viewed from the left ventral thorax.
Fig. B-38. Ultrasonograms of echogenic deposits between dorsal ruminal sac and left abdominal wall in 4 buffaloes affected with
traumatic pericarditis.
Fig. B-39. Changes in the contour of the reticulum in 8 buffaloes affected with traumatic pericarditis. A moderate degree of corrugation is
evident in A, while images from B to F show severe degree of corrugation.
Fig. B-40. Ultrasonograms of deposits of fibrinous tissue located among reticulum, dorsal ruminal sac and diaphragm. Deposits of fibrinous
tissue interspersed with fluid pockets appeared as echogenic areas cavitated by hypoechogenic areas (A). Deposits that consist solely
of fibrinous tissue are homogeneously echogenic (E and G). Heterogeneous contents are also evident (B, C, D, F and H). Ret;
reticulum.
Reticular abscesses
 Reticular abscesses have an echogenic capsule of varying thickness, which surrounds a
homogeneous hypoechogenic to moderately echogenic centre.
 The contents of an abscess are frequently partitioned by echogenic septa (Fig. B-41 and B-
42). Abscesses are usually caudoventral to the reticulum, but may be cranial or lateral to
the reticulum. Abscesses are often seen between the reticulum and the spleen, the
reticulum and the liver, or the reticulum and the omasum or the abomasum.
 Reticular abscesses vary in diameter from a few centimeters to more than 15 cm.
Occasionally, the thick capsule of an abscess produces an acoustic shadow. It is possible
to drain abscesses through an ultrasound-guided transcutaneous incision.
 However, the abscess must be immediately adjacent to and attached to the abdominal
wall, and the intercostal space over the abscess must be large enough.
Fig. B-41. Ultrasonograms of perireticular abscessation and echogenic deposits between reticulum, and dorsal ruminal sac.
Perireticular abscesses are imaged at the xiphoid cartilage near the reticular wall. The content of the abscess is either
anechoic (A) or partitioned by echogenic septae in B, C and D.
Fig. B-42. Ultrasonograms of reticular abscesses caudoventral to the reticulum and ventral to the craniodorsal blind sac of the rumen
of 4 cows with traumatic reticuloperitonitis viewed from the left ventral thorax. The contents appear partitioned with
echogenic septae in (a) and (b) and heterogeneous in (c) and (d)
Intestine
 For ultrasonography of the small intestine in cattle, the area from the tuber coxae to the
eighth intercostal space and from the transverse processes of the vertebrae to the linea alba
on the right side is examined.
 The appearance of loops of small intestine and their diameter, contents and motility are
assessed. The wall of the normal small intestine is 2–3 mm thick and its luminal diameter
is 2–4 cm. Evaluation of the contents of the small intestine in cattle is usually
straightforward because there is generally no gas. Unlike small animals and humans,
ruminants digest carbohydrates principally in the forestomachs, from which the gas is
eructated.
 The ultrasonographic appearance of the contents of the small intestine varies. Most
commonly, the intestine contains mucus or feed, which appears hyperechogenic. In these
cases, not only the intestinal wall closest to the transducer, but also the intestinal contents
and the wall furthest from the transducer can be visualized. This is also true for intestine
filled with fluid, which is hypoechogenic.
 In rare cases with gaseous intestinal contents, the intestinal wall closest to the transducer
appears as a hyperechogenic line adjacent to an acoustic shadow. Because of the reflection
of the ultrasound waves at the soft tissue–air interface, the intestinal contents and the
intestinal wall furthest from the transducer cannot be visualized.
 The cranial part of the duodenum is relatively easy to identify because it originates from
the abomasum and is in close proximity with the liver and gallbladder.
 The jejunum and ileum form the longest part of the small intestine and cannot be
differentiated from one another ultrasonographically. It is typical to see more than ten
loops of jejunum and ileum immediately adjacent to one another from the flank and lateral
abdominal wall, and from intercostal spaces 9 to 12. The loops of small intestine are
usually seen in cross-section and occasionally longitudinally (Fig. B-43). They can be
differentiated from the descending duodenum because they are not surrounded by
omentum, and because they are constantly in motion.
Fig. B-43. Ultrasonogram of the jejunum in a camel. Image was taken low in the right paralumbar fossa. J = jejunum; DS = dorsal; VT =
ventral.
Ileus of the small intestine

 When ileus of the small intestine is suspected, an ultrasonographic examination should
evaluate the diameter and motility of the small intestine. In cattle with ileus, the small
intestine is dilated in at least one area and has a diameter of more than 3.5 cm.
 Moreover, the motility of the small intestine is usually reduced or absent. Sometimes,
hypoechogenic fluid, attributable to transudation, is visible between the dilated loops of
intestine.
 Independent of the localization of ileus and its cause, the loops of small intestine are most
commonly imaged in cross-section, often in both cross-section and longitudinally, but
rarely only longitudinally (Fig.s B-44, B-45, B-46, B-47 and B-48).
Fig. B-44. Ultrasonographic findings in camels with intestinal obstruction. Ultrasonographic findings included distended intestinal
loops with markedly reduced or absent motility (A, B, C). Image D shows a hypoechoic fluid with fibrin (white arrow)
between intestinal loops; black arrow points to the intestinal wall. In one camel with partial obstruction, the intestinal lumen
contained localised hyperechoic material consistent with foreign body (E). Corrugated ruminal wall was scanned in one camel
with intestinal obstruction (F). IL = intestinal loops; FB = foreign body; F = fluid; DS = dorsal; VT = ventral.
Fig. B-45. Ultrasonogram of cross-sections and longitudinal views of dilated loops of jejunum in 2 buffaloes with an intussusception of
the distal jejunum. The transducer was placed in the 12th intercostal space. The contents of the loops viewed in cross-section
appear hypoechogenic and those of the loops viewed longitudinally have an echogenic appearance. (1) Abdominal wall, (2)
loop of jejunum in cross-section, (3) loop of jejunum viewed longitudinally. Ds: dorsal and Vt: ventral
Fig. B-46. Ultrasonogram of cross-sections through

dilated loops of jejunum in a sheep with
intussusception. The transducer was placed in the 12th
intercostal space. Abdominal effusions are apparent.
Fig. B-47. Ultrasonogram of a cross-section through

the dilated duodenum of a cow in which the
descending duodenum was obstructed. The transducer
was placed in the 11th intercostal space.
Fig. B-48. Ultrasonogram of a cross-section through

the dilated jejunum (J) of a camel. Image shows a
hyperechoic foreign body (FB) within the intestinal
lumen. Image was taken from the right lower
abdomen with 3.5 MHz sector transducer. SI, small
intestines.
Ultrasonography of the equine abdomen

 In equines, ultrasonography has a number of properties that are useful in imaging the
abdomen. It is a non-invasive, dynamic imaging technique, which can distinguish between
soft tissues of different echogenicity. Furthermore, it is easy to perform, and it allows the
immediate interpretation that is essential in the colic patient.
 Other methods of imaging the gastrointestinal tract, such as radiography and endoscopy,
are of limited value in the adult horse due to the size of the abdomen. In addition,
ultrasonography enables different regions of the gastrointestinal tract to be identified, and
their location, size, anatomical features (such as sacculations), luminal contents, and
motility to be assessed. The frequency, amplitude and velocity of the peristaltic
contractions can also be evaluated by B-mode, M-mode, and Doppler ultrasonography.
Limitations
 One of the problems of gastrointestinal tract ultrasonography in the horse is the acoustic
shadowing from gas and ingesta within the large intestine, and gas within the lungs. In the
horse, the large intestine is located along most of the lateral and ventral abdominal wall,
and the lungs overlie much of the cranial and dorsal abdomen.
 These structures reflect most or all ultrasound beam, making imaging of any underlying
structures difficult. In man, administering large volumes of oral fluids prior to imaging
reduces the reflection of ultrasound beam from the large intestine contents. This is not
practical in the horse and, instead, different techniques, such as combining transrectal and
transcutaneous imaging, may have to be used to visualize most of the abdomen.
 The ultrasonographer should always appreciate that it may not be possible to evaluate the
deeper cranial abdominal structure in the horse. This is a particular problem in patients
with large intestinal distension and, where feasible, sequential ultrasonographic
examinations are of value. Nonetheless, deeper structures may remain inaccessible and
some lesions may not be identified.
Ultrasonographic techniques for imaging equine abdomen
Ultrasonographic techniques
 Transcutaneous and transrectal ultrasonography are the two techniques used in the horse
(Table 1).
Table B-1. Comparison of transcutaneous and transrectal techniques of abdominal ultrasonography in the
horse
Transcutaneous ultrasonography Transrectal ultrasonography
Requires more patient preparation, including clipping. Requires little patient preparation.
Noninvasive, no risk to the anima. More invasive; risk of rectal tear similar to routine
rectal examination.
Requires lower frequency transducer, which may not be Reasonable imaging quality with 7.5 MHz
available in all practices. transducers, as routinely used for reproductive or
tendon imaging.
Only caudal region of the abdomen is accessible. Only caudal region of the abdomen is accessible.
Poor imaging quality due to imaging through the Excellent imaging quality regardless of body
abdominal wall; this is a particular problem in large or condition due to direct replacement of the transducer
obese adult patients. over the region of the intestine.
Gas within the large intestine, which lies along the body Bowel can be manipulated and the transducer is
wall, may obscure imaging of other structures. placed between the loops of large intestine.
Regions of intestine can only be identified by their location Regions of intestine can be identified by palpation,
within the abdomen and ultrasonographic features. allowing distinction between, for example, small and
large colon, based on their diameter and number of
taenial bands.
Transcutaneous imaging
 Transcutaneous ultrasonography requires routine skin preparation, including clipping of
the hair in most patients, cleansing of the skin and application of a coupling gel. The
transducer required depends on the size of the patient but, in general, a 2.5 to 5.0 MHz
convex or sector probe is adequate. Higher frequencies (5 to 10 MHz) will provide better
resolution but less depth of penetration; they are useful in animals with less body fat and
thinner skin, such as thoroughbreds and foals.
 Lower frequencies (2.5 to 3.5 MHz) will penetrate up to 30 cm, although the imaging
quality will be poor at this depth; these lower frequencies are required for deeper
abdominal structures, and in larger or obese patients.
 Transcutaneous ultrasonography should be used for imaging the ventral abdomen and the
right and left flank regions. The right and left flank should be imaged both within the
paralumbar regions and the intercostal spaces. Linear transducers can be used, but the
intercostal spaces in the horse are narrow, and a sector or convex probe is easier to
manipulate in this region.
Transrectal imaging
 Transrectal ultrasonography requires little patient preparation, apart from suitable restraint
of the animal, removal of the fecal contents and adequate lubrication with an obstetric
lubricant. It is performed in a similar way to transrectal reproductive ultrasonography;
and, as for rectal palpation techniques, the horse should be adequately restrained and care
taken to avoid trauma or iatrogenic damage to the rectum.
 Transrectal ultrasonography can be performed with either linear or convex probe, and
frequencies of 5 to 10 MHz are most suitable. With some machines, a penetration depth of
up to 20 cm can be achieved at these frequencies. This allows imaging of the cranial
abdominal structures that cannot be reached by rectal palpation alone, and is particularly
useful in large horses.
Normal ultrasonographic findings
Location of the abdominal organs
Transcutaneous ultrasonography
 The structures that may be identified by transcutaneous ultrasonography, and their
location within the abdomen, are listed in Table (B-2). Large intestine will be identified
consistently in every region. The presence of small intestine is more variable; in most
horses, small intestine can only be imaged in the ventral abdomen.
 It should be possible to identify the liver, spleen, and kidneys in all normal animals (Fig.
B-49).
Fig. B-49. Ultrasonogram of the normal spleen and stomach in a horse obtained from the left 9th intercostal space (ICS). The
stomach wall has a hyperechoic curvilinear appearance with lack of sacculations.
Table B-2. Transcutaneous abdominal ultrasonography in the horse: structures that may be identified and their location within the
abdominal cavity.
Region of the abdomen Abdominal structures
Cranial right flank Large intestine (sternal flexture, diaphragmatic flexture, right ventral colon, right dorsal colon), small intestine,
duodenum, liver.
Caudal right flank Large intestine (right ventral colon, right dorsal colon), cecum, right kidney.
Cranial left flank Large intestine (sternal flexture, diaphragmatic flexture, left ventral colon, left dorsal colon), small intestine, liver,
stomach.
Caudal left flank Large intestine (pelvic flexture, left ventral colon, left dorsal colon), left kidney, spleen.
Cranioventral abdomen Large intestine (sternal flexture, left ventral colon, right ventral colon), small intestine, spleen.
Caudoventral abdomen Large intestine (pelvic flexture, left ventral colon, right ventral colon), small intestine, spleen, bladder.
Transrectal ultrasonography
 During transrectal ultrasonography, the transducer is manipulated in an arc across all
regions of the abdomen, including dorsal structures such as the aorta, iliac arteries,
sublumbar lymph nodes and kidneys. Table lists abdominal structures identified and their
location. There is some variation between different patients; for example, the right kidney
and renal arteries may not be accessible in larger patients.
Table B-3. Transrectal abdominal ultrasonography in the horse: structures that may be identified and their location within the abdominal
cavity
Region of the abdomen Abdominal structures
Left dorsal region Large intestine (pelvic flexture, left dorsal colon), small intestine, small colon, spleen, aorta, iliac arteries, left
kidney, left renal artery, left ovary
Left ventral region Large intestine (pelvic flexture, left ventral colon), small intestine, spleen, bladder, uterus
Right dorsal region Large intestine (right dorsal colon), small intestine, small colon, cecum, aorta, iliac arteries, right kidney, right
renal artery, right ovary
Right ventral region Large intestine (right ventral colon), small intestine, cecum, bladder, uterus
 Neither of the ultrasonographic technique will consistently distinguish different regions of

the large intestine. Characteristics such as sacculations, the orientation of contractions and
the location of the intestine can give an indication in the normal horse. However, reliable
identification, particularly in the colic patient, depends on rectal palpation combined with
ultrasonographic findings.
Ultrasonographic features of the small intestine

 The small intestine can be recognized by its small diameter, fluid contents, and frequent
peristaltic contractions (Fig. B-50). It has a tubular appearance on ultrasonography, and
images vary between transverse and longitudinal sections.
 The contents are predominantly fluid, but vary in echogenicity depending on the amount
of fluid, ingesta and gas. Fluid has a hyperechoic appearance; ingesta is echogenic, often
producing a heterogeneous pattern with mixed fluid and particulate matter visible, but
without acoustic shadowing; gas is highly reflective, producing a hyperechoic reflection
with acoustic shadowing.
 Normal small intestinal contractions cause rapid propulsion of ingesta and almost
occlusion of the small intestinal lumen.
Fig. B-50. Ultrasonogram of the normal spleen, jejunum (J) and left ventral colon (LVC) obtained from the left 17th ICS.
Ultrasonographic features of the cecum

 The cecum can be identified by its location within the right caudal abdomen, its large
diameter, sacculations and contractions. The cecal contents may be either solid, liquid, or
mixed in the normal horse, but are usually highly echogenic, causing acoustic shadowing.
 Only the cecal wall, and the cecal contents to a few centimeters depth, can be imaged and
motility is evaluated from the movement of the cecal wall and the underlying hyperechoic
shadow (Fig. B-51).
Fig. B-51. Cecum obtained from the right flank ventral to the sacrum. The cecum has hyperechoic wall with presence of sacculations.
Ultrasonographic features of the large intestine

 The large intestine has a similar ultrasonographic appearance to the cecum. The intestinal
wall is visible, but the underlying contents produce a bright hyperechoic shadow so that
only the surface can be imaged.
 Sacculations can be identified ultrasonographically, and these allow the distinction
between the dorsal and ventral colon (Fig. B-52, B-53).
Fig. B-52. Ultrasonogram of the normal dorsal colon (DC), spleen and the LVC obtained from the left 17th ICS. Notice the
echotexture of the spleen. DC appears circular with echogenic wall. The LVC appear sacculated.
Fig. B-53. Ultrasonogram of the normal spleen and left dorsal colon (LDC) obtained from the 13th ICS in the left dorsal portion.
Ultrasonographic findings in the colic horse

Principles of ultrasonography in the colic patient

 Gastrointestinal disease can cause changes in the location, size, motility, contents and the
wall of the intestine. Interpretation of these changes can help to determine site and type of
lesion.
 Changes in the location of the intestine occur with distension, displacement by another
structure (such as abdominal mass), or abnormal positioning of the intestine. Intestinal
distension is caused by an obstruction, leading to a build-up of gas, ingesta and fluid;
obstruction may be simple (as feed impaction) or strangulation (as volvulus), partial or
complete. Here we describe the main ultrasonographic characteristics in main types of
colic in the horse.
Flatulent colic
 Large intestinal lesions in horses suffering from flatulent colic are usually characterized
by gas distension of the large intestine, which may obscure other abdominal structures.
 In these cases, other organs are often not visible on transcutaneous ultrasonography, and a
combination of transcutaneous and transrectal techniques may be required to image
structures such as the left kidney and small intestine (Fig. B-54).
Fig. B-54. Ultrasonogram of the cecum, left ventral colon (LVC) and right ventral colon (RVC) in 4 horses with flatulent colic. In A,
the cecal wall appears echogenic with absence of sacculations. In B, LVC appears with an echogenic wall with absence of
sacculations. In C, RVC appears with thin wall that appear echogenic with absence of sacculations. In D, RVC appears with
absence of sacculations and with increased wall thickness. These organs contain much gas that hinders visualization of their
contents.
Impaction colic
 In general, impactions are diagnosed on rectal palpation. However, impactions in the
cranial abdomen, such as the sternal flexture, may be inaccessible.
 Ultrasonographic findings of distended large intestine with reduced motility may be useful
in these cases. Impaction in the sternal ventral colon are characterized by a loss of the
normal sacculations due to intestinal distension (Fig. B-55)
Fig. B-55. Ultrasonogram of the cecum and dorsal colon (DC) in 4 horses with impactive colic. Notice impaction of these organs with
ingesta.
Torsion colic
 Ultrasonography can be difficult in some horses with large intestinal torsions due to
severe abdominal pain. If examination is possible, ultrasonographic changes associated
with strangulating large colon torsions are a thickened intestinal wall, due to intraluminal
edema and hemorrhage, absence of motility, and distended small intestinal loops (Fig. B-
56 and B-57).
 Ultrasonography can be used to identify compromised intestine, allowing an earlier
diagnosis. The increase in wall thickness reflects the degree of edema and hemorrhage,
and hence the prognosis.
Fig. B-56. Ultrasonogram of the jejunum and left ventral olon (LVC) in a horse with obstructive colic. This image was obtained from
the left flank region caudal to the costal arch. The jejunum is distended and contents are more echogenic. LVC appear with
no sacculations.
Fig. B-57. Ultrasonogram of the spleen, left ventral colon (LVC) and dorsal colon (DC) in 2 horses with spasmodic colic. Image was obtained from the left
13 ICS. The spleen appears with normal echotexture, the LVC appears also with normal echogenic wall and have sacculations. Only
hyperstalsis is observed.
Spasmodic colic
 The normal intestine has a continual intrinsic motility, which propels food through the
gastrointestinal tract and facilitates digestion and absorption. In contrast to other
gastrointestinal diseases, hypermotility as an important finding in horses suffers from
spasmodic colic (Fig. B-58).
Other abdominal disorders detected by ultrasonography

Mesothelioma
 Ultrasonography is useful for the early prediction and prognosis of mesothelioma in
bovine and for ruling out other causes of non-inflammatory ascites such as right-sided
heart failure, caudal vena cava thrombosis, and portal hypertension.
 The huge amount of abdominal fluid, as well as the tumor masses, can be clearly
visualized (Fig. B-59). Ultrasonography combined with ultrasound-guided fine-needle
aspiration and biopsy yielded a diagnosis and helped in determining the prognosis of the
animal. Therefore, early ultrasonographic detection of abdominal masses, followed by
percutaneous ultrasound-guided biopsy of the lesion is encouraged for field veterinarians
in the diagnosis of such tumors.
Fig. B-59. Ultrasonograms in a cow with mesothelioma. Ultrasonographic picture of ascites taken at the left 6th intercostal space with a
3.5 MHz linear transducer (A). Ultrasonographic appearance of the greater omentum viewed at the left ventral abdomen.
The greater omentum is surrounded by ascetic fluid and contains multiple nodules (arrows) (B). Ultrasonographic
appearance of the lateral aspect of the abdomen taken at the right 11th intercostal space where multiple coalesced nodules
(arrow) was scanned (C).
Fat necrosis
 Necrosis of mesenteric or other abdominal or retroperitoneal fat is a common finding in
several domestic animals, and also in humans. The pathogenesis is poorly understood, but
there appear to be a number of causes.
 In humans, the condition may be encountered following localized trauma to fat tissue as
an accompaniment of pancreatitis.
 In domestic animals, the condition is usually attributed to the liberation of pancreatic
enzymes in pancreatitis, to pressure and trauma, or other factors such as febrile conditions,
diet, rapid cachexia and genetic predisposition.
 In addition, obesity resulting from excessive energy intake in the growing stage and
subsequent disturbances in lipid metabolism are also related to the occurrence of fat
necrosis in the cow.
 In cattle, fat necrosis is characterized ultrasonographically by the presence of echogenic
masses of various sizes and shapes located in the omentum (Fig. B-60), mesentery of the
intestines (Fig. B-61), and perirenal tissues (Fig. B-62).
Fig. B-60.Ultrasonograms in 4 cows with fat necrosis. Echogenic masses are visualized located in the omentum. Upper images are
taken from the right flank, while the lower images are taken during transrectal examination.
Fig. B-61. Ultrasonograms in 2 cows with fat necrosis. Echogenic masses are visualized around the duodenum. Images are taken from
the 9th intercostal space on the right side.
Fig. B-62. Ultrasonograms in 4 cows with fat necrosis. Echogenic masses are visualized around the kidney. Images are taken from the
12th intercostal space on the right side.
Retroperitoneal abscessation
 In the diagnosis of abdominal lesions in horses, ultrasonography provides results that are
superior to radiography, and it is more available and accessible, especially for adult
horses.
 Accuracy of ultrasonography in confirming a diagnosis of mesenteric abscesses is
dependent on the quality of the image obtained, the depth of penetration required, the
image quality of the equipment, the availability of a good window for imaging, the skill of
the sonographer, the completeness of the examination, and the size, appearance, and
location of the lesion (Fig. B-63).
 Differential diagnose includes abscessiation, neoplasia or hemorrhage. Ultrasonography is
helpful to obtain a percutaneous needle aspirate for bacteriologic evaluation, and it
facilitates intralesional antibiotic treatment and drainage as the thick abscess capsule
prevents the antibiotic spread.
 Ultrasonography, combined with fine-needle aspiration, yields a diagnosis and helps in
determining the prognosis of the case.
Fig. B-63. Ultrasonograms from an 8-year-old Thoroughbred mare with mesenteric abscess. A- Sonogram obtained at day 0 where a
mass with a thick echogenic rim (arrow) with homogenous and echogenic internal contents was identified. B- The mass was
located close to the liver deforming its right lobe margins. C- Fine-needle aspiration technique was used to drain the content
of the lesion. D- Image obtained at day 17 after initial examination where the mass became smaller and had hypoechoic
contents with the capsule no longer seen and a fibrous tissue (arrow) is seen surrounding the lesion. These images were
obtained at the right 15 intercostal space by the use of a 3.5 MHz convex transducer at a displayed depth of 15 cm.
Ascites
 Peritoneal effusion is visible ultrasonographically as an accumulation of fluid without an
echogenic margin and it is restricted to the reticular area (Fig. B-64, B-65, B-66 and B-
67).
 Depending on the fibrin and cell content, the fluid may be anechoic or hypoechogenic.
 Fibrinous deposits are easily identified in the fluid, and sometimes, bands of fibrin are
seen within the effusion.
 Occasionally, the peritoneal effusion is considerable and extends to the caudal abdomen.
Fig. B-64. Changes in the contour of the reticulum in 2 buffaloes affected with traumatic pericarditis. Ultrasonograms show
abdominal anechoic effusion with fibrinous echogenic deposits on the reticulum and craniodorsal blind sac of the rumen.
Fig. B-65. Ultrasonogram in a cow with right-sided heart failure. Abdominal anechoic effusion with fibrinous echogenic deposits
on the reticulum and craniodorsal blind sac of the rumen.
Fig. B-66. Ultrasonograms in a horse with right-sided heart failure. Abdominal anechoic effusions are apparent in A. In the same case,
pericardial (B) and pleural (C) effusions are also evident.
Fig. B-67. Ultrasonogram of the abdomen in a camel showing abdominal anechoic effusion (F) with fibrinous echogenic deposits (ED).
Int = intestine.
Peritonitis
 In animals affected with peritonitis, large quantities of echogenic fluid, with or without
fibrin, with adhesions of the abdominal viscera to the peritoneum or to other viscera can
all be imaged in patients with peritonitis (Fig. B-68, B-69, B-70).
Fig. B-68. Ultrasonograms from a horse with chronic fibrinous peritonitis. Image was obtained from the lower right abdomen.
Fig. B-69. Chronic fibrinous peritonitis in a beef cow. Fibrin deposits are detected between the rumen and left abdominal wall.
Fig. B-70. Ultrasonograms from a ram with chronic fibrinous peritonitis. Left sonogram was obtained on the first day of admission, while the right
image was taken 2 weeks later. Fine-needle aspiration technique was used to drain the content of the abdomen where pyogenic material was
aspirated. Images were obtained from the lower right abdomen by the use of a 7.5 MHz linear transducer at a displayed depth of 10 cm.
Chapter 4: Ultrasonography of the Liver
Introduction
 There are many indications for using ultrasonography to scan the liver, because the
existing diagnostic methods for detecting liver diseases, such as hepatospecific enzyme
tests, are insufficient.
 Metabolic disorders lead to diffuse changes of the liver structure and size, whereas
abscesses and tumors usually induce focal changes.
 A complete ultrasonographic assessment of the liver should give detailed information
about the size, the position, the parenchymal pattern of the liver, and the localization of the
vessels.
 Various hepatic diseases (e.g., hepatic abscess, fatty degeneration and obstructive
cholestasis) can be unequivocally diagnosed through ultrasonography and examination of
liver biopsy and aspirate samples collected under ultrasonographic guidance.
 Ultrasonography can also yield a highly reliable diagnosis of other problems, including
thrombosis of the caudal vena cava.
 In ruminants, the ultrasonographic examination is performed on the right side of the
abdomen while the animals are standing. Hair is clipped and skin shaved between the 7th
intercostal space and a handbreadth behind the last rib. After the application of the
transmission gel, the 12th intercostal space is scanned by using a 3.5MHz transducer.
Initially, the texture of the liver, hepatic and portal veins, and visceral and diaphragmatic
surface are examined.
 Hepatic diseases are of great importance in farm animals. Fascioliasis, hepatic abscesses,
hepatic neoplasia, metabolic disturbances (e.g., fatty liver disease) and diseases of major
vessels (e.g., thrombosis of the caudal vena cava) caused by hepatic abscesses that have
broken into the vein are some examples.
 Until recently, diagnosis of many hepatic diseases was difficult because signs may be
nonspecific. In many cases, diagnostic methods such as hepatospecific enzyme tests are
insufficient.
 A complete ultrasonographic examination of the liver should give detailed information
about the size, the position, and the ultrasonographic parenchymal pattern of the liver, the
size and the position of the gallbladder and the intra- and extrahepatic bile ducts, and the
topography of the major vessels.
 Ultrasound-guided collection of hepatic biopsy samples, centesis and aspiration of
abscesses, and cholecystocentesis and aspiration of bile samples (for examination for
fluke eggs and determination of bile acids concentration) can be performed safely.
 The liver is scanned fully in both transverse and longitudinal sections by gently angling
and moving the transducer from cranial to caudal and from right to left. Longitudinal
views of the liver refer to the ultrasound beam being aligned along the long axis of the
patient. The characteristic interface between the air-filled lung and the liver, which is seen
as a curved hyperechoic line, is often referred to (incorrectly) as the diaphragm. The
cranial aspect of the liver adjacent to the diaphragm must be examined and the caudal tips
of the liver lobes must also be seen.
Normal appearance
 The parenchymal pattern of the normal liver consists of numerous weak echoes
homogenously distributed over the entire area of the liver. Portal and hepatic veins can be
easily seen within the normal texture. Portal veins can be differentiated from hepatic veins
by its echogenic walls and by stellate ramification. The caudal vena cava usually has a
triangular shape on cross section. Unlike the caudal vena cava, the portal vein usually has
a circular diameter (Fig. B-71, B-72 and B-73).
Fig. B-71. Ultrasonogram of normal liver and its normal vessels in 3 cows. Images were taken from the 11th intercostal space using 3.5
MHz linear transducers. The portal vein (PV) and its stellate ramification can be easily seen in B. Compared to the circular
shape of the PV on cross section in A, the caudal vena cava (CVC) has a triangular shape on cross section in C. In contrast
with the hepatic veins (HV), the wall of the portal vein, is characterized by an echogenic border. L: Liver
Fig. B-72. Ultrasonogram of normal hepatic echotexture in a horse. Image A was obtained from the right 9th ICS. Right dorsal
colon (RDC) is medial to the right lobe of the liver and has no sacculations. The duodenum (D) is collapsed in this
image, but the ingesta can be imaged moving through the duodenum with periodic duodenal contractions. Image B was
obtained from the 16th ICS. Right ventral colon (RVC) appears sacculated and the peristaltic activity can be detected.
Fig. B-73. Ultrasonogram of normal liver and its normal vessels in a camel. Images were taken from the right 10th intercostal space
using 3.5 convex (left) and 5.0 MHz linear (right) transducers. The portal vein (PV) and its stellate ramification can be easily
seen. In contrast with the hepatic veins (HV), the wall of the portal vein, is characterized by an echogenic border.
 The gallbladder has an image type of a fluid-filled vesicle. The normal gallbladder has a
pear-shaped cystic structure with variable size. The gallbladder is situated between the 9th
and the 11th intercostal spaces. It has an image of fluid-filled vesicle and thus appears
almost black and surrounded by a thin white rim (Fig. B-74).
Fig. B-74. Ultrasonogram of normal liver and gallbladder in a cow. Image was taken from the 9th intercostal space using a 3.5 MHz
linear transducer. The gallbladder has a pear-shaped cystic structure with variable size and appears anechoic and surrounded by a thin,
white rim.
Abnormal appearance
Diffuse hepatic disease

 Many diseases result in diffusing hepatic damage with nonspecific ultrasonographic
features; the echogenicity may be increased or decreased, and the liver is uniformly
affected.
 Fatty liver degeneration is the most common hepatic disease with a diffuse distribution of
lesions. Hepatic fibrosis and congestion are less often seen.
Fatty liver disease

 There is a strong positive association between the severity of fatty liver disease and the
ultrasonographic picture. In cases of diffusing fatty liver, the number and intensity of the
internal echoes increase as the severity of the increases (Figs. B-75 and B-76).
Fig. B-75. Ultrasonogram of a mild degree of fatty degeneration in 2 Holstein cows. Image was taken from the 11th intercostal space using a
3.5 MHz sector transducer. The portal vein and its stellate ramification can be easily seen in cow 1. The caudal vena cava has a
triangular shape on cross section in cow 2.
Fig. B-76. Ultrasonogram of moderate degree of fatty degeneration in 2 Holstein cows. Image was taken from the 11th intercostal space
using a 3.5 MHz sector transducer. The caudal vena cava in cow 1 has a rounded shape compared to the triangular shape on
cross section in cow 2.
 In advanced stages of the fatty liver, the parenchyma appears in white color on the
ultrasonograms, and is difficult to be differentiated from the surrounding tissue (Figs. B-
77 and B-78).
Fig. B-77. Ultrasonogram of advanced degree of fatty degeneration in 3 Holstein cows. Image was taken from the 11th intercostal space
using a 3.5 MHz linear transducer. The liver appears in white color on ultrasonograms and is difficult to be differentiated from
the surrounding tissue.
Fig.
B-78. Ultrasonograms of fatty infiltration of the liver in 5 camels. Image was taken from the 11th intercostal space. The liver
appears hyperechogenis on ultrasonograms. The caudal vena cava (CVC) has a triangular shape on cross section.
 In severe cases of fatty liver, the echoes weaken as the distance from the abdominal wall
increases because the fat-containing hepatocytes enhance acoustic impedance.
Consequently, the region near the abdominal wall is hyperechoic, whereas areas that are
more distant are hypoechoic or cannot be imaged at all (Figs. B-79 and B-80).
Fig. B-79. Ultrasonogram of severe fatty degeneration in a Fig. B-80. Ultrasonogram of severe fatty degeneration in a camel.
Holstein cow. The transducer was placed in the 10th The transducer was placed in the 11th intercostal space
intercostal space using a 3.5 MHz sector transducer. The using a 7.5 MHz linear transducer. The liver moderately
liver moderately hyperechoic near the abdominal wall hyperechoic near the abdominal wall and cannot be
and cannot be visualized very far from the abdominal visualized very far from the abdominal wall.
wall.
 Together with guided biopsy, hepatic ultrasonography is essentially useful in the detection
and characterization of cases with focal fatty infiltration.
 Compared to the hepatic parenchyma in the normal cow, the liver discloses an area of
increased echogenicity (Fig. B-81). Differential diagnosis include true hepatic tumor, such
as hepatocellular and cholangiocellular adenomas and carcinomas.
Fig. B-81. Ultrasonogram of focal fatty infiltration in a Holstein cow. The hepatic sonogram shows a hyperechoic area located anterior
to the portal vein (PV). The ultrasonogram revealed portal blood flow within the lesion, attesting to the fact that it was not a
true hepatic tumor but fatty infiltration of the liver. Diagnosis was confirmed by liver biopsy. ND; needle path.
 Serial imaging of the liver during treatment follow-up could also be used as a prognostic
indicator in cows with fatty liver infiltration (Fig. B-82).
Fig. B-82. Hepatic ultrasonograms in a cow with fatty liver. At admission, the liver parenchyma was completely anechoic (A). On day 11 of
treatment, the hepatic parenchyma was moderately echogenic (B). At day 15 the hepatic parenchyma was similar to normal liver
image and the blood vessels could be easily evaluated (C).
Hepatic fibrosis
 In cows with chronic fascioliasis, there are variably sized nodules, which are hyperechoic.
 In some advanced cases, where there is ongoing inflammation/ fibrosis, dystrophic
mineralization may be present, seen on the scan as hyperechoic areas casting an acoustic
shadow (Fig. B-83).
Fig. B-83. Diffuse necrosis and cirrhosis in a buffalo with chronic fascioliasis. There is an overall increased echogenicity of the hepatic
parenchyma (A). Areas of mineralization within the parenchyma can be seen reflecting chronic inflammation (B).
Focal disease
Hepatic abscess
 Unlike the hematologic findings, the results of ultrasonographic examination are of
substantial importance in the diagnosis of hepatic abscesses. Single (Fig. B-84) or multiple
(Fig. B-85) abscesses result in circumscribed structural changes in the hepatic
parenchyma.
 The contents of the abscess range from anechoic to hyperechoic (Fig. B-86), homogenous
or heterogeneous. Often, the abscess is surrounded by a capsule that appears as an
echogenic line that demarcates the content of the abscess from the hepatic parenchyma.
The abscess may be divided into several chambers by septa. The presence of gas leads to
pronounced ultrasonographic reflections that are sometimes associated with shadow
artifacts.
Fig. B-84. Ultrasonogram of hepatic abscesses in 2 cows. Image was taken from the 9th and 11th intercostal space, respectively using a
3.5 MHz linear transducer. The contents appear echogenic. Confirmation of the preliminary diagnosis depends on aspiration
by a biopsy needle.
Fig. B-85. Ultrasonogram of multiple hepatic abscesses in a cow with subacute ruminal acidosis. Image was taken from the 11th
intercostal space.
Fig. B-86. Ultrasonogram of hepatic abscess (AB) in a camel. Image was taken from the 11th intercostal space with 3.5 MHz sector
transducer. Image shows also a calcified bile duct with acoustic shadowing (AS). PV, portal vein; AE, acoustic enhancement.
Bile ducts and gallbladder abnormalities

 Normally, the intrahepatic bile ducts are not visible by ultrasonography. They are ramified
(along with the branches of the portal vein) in the periphery of the liver, they become
confluent as the right and left hepatic duct, and then they form the common hepatic duct.
 The cystic duct joins the common hepatic duct to form the short, but wide, choledochous
duct. In cattle, the choledochous duct runs to the cranial part of the sigmoid flexure of the
duodenum, which is situated 50-70cm from the pylorus at the hepatic portal. The
choledochous duct joins the duodenum at the major duodenal papilla.
 Ultrasonographic examination is important in the diagnosis of diseases of the bile ducts. It
supplements the results of clinical examination and hematologic and biochemical testing,
and in many cases, it provides a reliable diagnosis.
Calcification of the bile duct

 Calcification of the bile ducts results from chronic fascioliasis. The result is circumscribed
changes in the ultrasonographic appearance of the liver. Calcified bile ducts are
hyperechoic and are characterized by intense echoes accompanied by a distal acoustic
shadow (Fig. B-87 and B-88).
Fig. B-87. Ultrasonogram of calcified bile ducts in one cow. The transducer was placed in the 11th intercostal space. Note the acoustic
shadowing of the affected bile duct (arrow).
Fig. B-88. Ultrasonogram of calcified bile ducts in 2 camels and a buffalo (C). The transducer was placed in the 11th intercostal space. Note
the acoustic shadowing (AS) of the affected bile ducts.
Cholangitis, and cholestasis

 Cholestasis is the stoppage of the bile flow. The diagnosis of obstructive cholestasis can
usually be based on observation of dilated bile duct.
 Ultrasonography can be used to locate the obstruction. The location is usually identified
by the dilatation pattern of the intra- and extrahepatic bile ducts and of the gallbladder
((Fig. B-89).
Fig. B-89. Ultrasonogram of gallbladder (GB) and cystic duct dilatation (white arrow) in 2 Holstein cows with obstructive cholestasis
and cholangitis as a result of hepatic abscess. The transducer was placed in the 9th intercostal space.
 Dilatation of the gallbladder alone is not an indication of cholestasis. Many anorectic cows
have no reflex stimulus for emptying of the gallbladder, and gallbladder volume increases
without impairment of bile flow (Fig. B-90).
 However, thickening of the gallbladder wall and abnormal contents (e.g., concernment or
sediment) are considered pathologic (Fig. B-91).
Fig. B-90. Ultrasonogram of a distended gallbladder in a buffalo suffered from 3-days anorexia. The transducer was placed in the
10th intercostal space.
 The contents of the gallbladder may appear to be heterogeneous or homogenous.

Homogenous contents usually appear echogenic, and heterogeneous contents often consist
of echogenic sediment and a hypoechoic supernatant (Fig. B-92).
Fig. B-92. Ultrasonogram of distended gallbladder in a Holstein cow that fasted for 4 days. The gallbladder (GB) contains echogenic
sediment (black arrow) and an anechoic supernatant (white arrow). The transducer was placed in the 9th intercostal space.
 In the differential diagnosis, it is important to note that thickening of the gallbladder wall
without other signs of cholestasis suggests edematous (Fig. B-93) rather than
inflammatory (Fig. B-94) changes.
 Edema of the gallbladder wall is sometimes apparent as a result of right-sided cardiac
insufficiency.
Fig. B-93. Ultrasonogram of the gallbladder in 2 Holstein cows with right-sided heart failure due to traumatic pericarditis. The
gallbladder (GB) wall is edematous and therefore thickened. The transducer was placed in the 9th intercostal space.
Fig. B-94. Ultrasonogram of the gallbladder in 2 Holstein cows with chronic cholangitis due to fascioliasis. The gallbladder (GB) wall is
severely edematous, thickened and hyperechoic. The transducer was placed in the 9th intercostal space.
Caudal vena cava

 Congestion in the systemic circulatory system results in the dilatation of the caudal vena
cava.
 Causes include right-sided cardiac insufficiency, thrombosis of the caudal vena cava, and
compression of the caudal vena cava in the thorax or in the subphrenic region by space-
occupying lesion. The ultrasonographic appearance of the caudal vena cava is a
substantial aid in diagnosing congestion in the systemic circulation.
 The caudal vena cava loses its normal triangular shape when it is congested, and becomes
round to oval on ultrasonograms; at the same time, the diameter of the vein increases. In
addition, the hepatic veins that join the caudal vena cava (especially the right hepatic vein)
are prominent and markedly dilated (Fig. B-95).
 In animals with congestion of the caudal vena cava, distension of the jugular vein
indicates right-sided cardiac insufficiency, whereas normal jugular vein indicates
obstruction or compression of the caudal vena cava between the liver and the heart.
Fig. B-95. Ultrasonogram of liver and congested caudal vena cava, imaged from the 11th intercostal space using a 3.5 MHz convex
transducer. The caudal vena cava has an oval shape on cross section due to right-sided cardiac insufficiency in 2 cows (A& B) and 2
buffaloes (C& D). The right hepatic vein is dilated in A. HV, hepatic vein ; CVC, caudal vena cava.
Thrombosis of the caudal vena cava and hepatic vein

 Obstruction of the caudal vena cava by a thrombus results in congestion of the vessel.
Consequently, the diameter of the caudal vena cava increases resulting in an oval to
circular appearance when imaged in cross section.
 The thrombus can rarely be seen via ultrasonography because it is usually situated more
cranially and obscured by the lungs. In addition, with congestion of the caudal vena cava,
the liver veins that join it, particularly the right hepatic vein, are markedly dilated and
prominent, the liver borders are blunt and there is edema of the gallbladder wall.
Sometimes a liver abscess and thrombosis of the hepatic vein can be seen (Fig. B-96, B-
97, B-98 and B-99).
Fig. B-96. Ultrasonogram of the liver, caudal vena cava, and hepatic vein. (A) Thrombosis of the right hepatic vein. The thrombus
located between the electronic calipers appears as a large oval echogenic structure that partially occludes the vein (T). (B) An
embolus obstructs a collateral hepatic vein (T). Arrow shows aneurysm of the vein. (C) A longitudinal scan of a severely
distended right hepatic vein. (D) Hepatic abscess between the electronic calipers. Notice the hyperechogenic center caused by
necrotic debris and the hypoechoic rim. CVC, caudal vena cava; R. kid, right kidney; L, liver; HV, hepatic vein; PV, portal
vein; P, pancreas.
Fig. B-97. Ultrasonogram of liver and congested caudal vena cava containing an echogenic thrombus in 2 cows, imaged from the 11th
intercostal space using a 3.5 MHz convex transducer. The caudal vena cava has an oval shape on cross section and contains
an echogenic thrombus. T, thrombus, R. kid, right kidney.
Fig. B-98. Ultrasonogram of liver and congested caudal vena cava, imaged from the 11th intercostal space using a 3.5 MHz linear
transducer. The caudal vena cava has a rounded shape on cross section due to right-sided cardiac insufficiency. HV, hepatic
vein ; CVC, caudal vena cava.
Fig. B-99. Ultrasonogram of the hepatic vein and the portal vein (PV) in a cow imaged in the 11th intercostal space. Notice the
thrombus (THR) (arrow) inside the dilated hepatic vein.
Chapter 5: Ultrasonography of the Pancreas
Introduction
 Ultrasonography is routinely used to diagnose pancreatic diseases in humans and in
animals, and it has gained on increasing importance for detecting pancreatitis in the cat.
 In cattle, pancreatic ultrasonography is in its infancy; but with a clear understanding of the
physical principles of ultrasound, a detailed knowledge of normal and abnormal
pancreatic ultrasonic anatomy, and with experience, ultrasonic imaging of the pancreatic
diseases in cows should assume an important role in veterinary practice.
 Images of the pancreatic region concur with the normal ultrasonic anatomy of the bovine
pancreas.
Imaging procedure
 The hair is clipped and shaved over an area between the right 9th intercostal space to
approximately 12 cm caudal to the costal arch. Instead of the ultrasonic coupling gel, a
generous amount of alcohol is applied to the skin as a transmission medium.
 With the transducer placed parallel to the ribs of the cow in a standing position, the entire
shaved region is scanned in a systematic fashion caudal to cranial as far as the costal arch
and the intercostal spaces, nine to twelve, were scanned dorsoventrally.
 The pancreatic body and right lobe of the organ can be seen easily; however, the left lobe
cannot be imaged.
Normal appearance
 The pancreatic body and the right lobe of the organ are consistently identified as a
triangular structure. The echogenic pattern of the pancreas is homogeneous throughout,
and can be clearly differentiated from that of adjacent structures.
 The pancreas is slightly hyperechogenic compared to the liver parenchyma. The accessory
pancreatic duct appears as a tubular anechoic structure, with a well-defined
hyperechogenic wall.
 The pancreaticoduodenal vein appears as a band-like structure coursing from the
duodenum along the right lobe of the pancreas to where it joined the portal vein (Fig. B-
100 and B-101).
Fig. B-100. Normal pancreatic sonograms. The body and right limb of the pancreas are visible as a triangular structure (A). The
pancreaticoduodenal vein (PDV) appears as a band-like anechoic structure coursing from the duodenum along the right lobe
of the pancreas to where it joins the portal vein (PV) (B). In both sonograms, the margins of the uniformly echogenic
pancreas are designated by arrows.
Fig. B-101. Normal pancreatic sonogram in a camel. The pancreaticoduodenal vein (PDV) appears as an anechoic structure within the
pancreas. Compared to the liver, the pancreas appears relatively echogenic.
Pancreatic biopsy
 In cattle, as the pancreas is situated on the visceral surface of the liver, the biopsy area is
only accessible transhepatically, carrying a significant risk of haemorrhage. Thus, the
determination of platelet count, prothrombin time, and activated partial thromboplastin
time are necessary prior to biopsy. To obtain adequate restraint, cows are lightly sedated
with xylazine (0.07 mg/kg body weight, intravenously) and the region is infiltrated with
10mL of 2% procaine hydrochloride.
 A free-hand biopsy technique is used. After a route for pancreatic puncture is chosen, for
ease of needle passage the skin incises by the tip of a scalpel blade No. 20. A
14G×150mm spinal biopsy needle is introduced and sonographically guided

transhepatically toward the pancreas. The needle with a plain stylet is advanced until
contact with the surface of the pancreas (Fig. B-102). When a suitable site and angle are
identified, the needle is pushed through with a slight thrust. The plain stylet is then
withdrawn, and a forked stylet inserted and the pushed in a further 1–2 cm in a twisting
fashion. Both the needle and forked stylet are then removed with a sample of pancreatic
tissue. To obtain enough tissue for histological examination, the pancreas is sampled at its
thicker part.
Fig. B-102. Ultrasonogram of normal hepatic texture. Notice the ultrasound- guided biopsy needle (arrow) appears as a sharp bright
line. The image was taken in the 11th intercostal space before the biopsy needle contacts with the surface of the pancreas. L,
liver; ND, needle; P, pancreas; PV, portal vein.
Abnormal appearance
Pancreatitis
 The sonographic changes associated with pancreatitis vary with severity and chronicity.
Decreased echogenicity in acute pancreatitis reflect edema, hemorrhage, and necrosis.
 Experimentally, the appearance of the inflamed pancreas can vary from an enlarged
homogeneous organ through an enlarged but ill defined hypoechoic structure, to a
complex mass or multiple heterogeneous masses (Fig. B-103).
Fig. B-103. Pancreatic imaging after inducing pancreatitis. (A) image taken after 24 h. An overall increase in echogenicity is clear. (B)
Image taken after 72 h. Hypoechogenic foci can be identified within the right lobe of the pancreas. (B) The echogenicity of
landscape-like hypoechoic region in (C) seem to increase in echogenicity (D).
Pancreolithiasis
 Pancreatic stones are formed primarily from calcium carbonate, proteins and
polysaccharides. They may be single or multiple, existing as small concretions or well-
developed calculi 1 to 2 cm in diameter.
 Moreover, pancreatic calculi are white or dull brown in color. In cattle, ultrasonography is
an effective noninvasive means of identifying pancreatic calculi (Fig. B-104).
Fig. B-104. Pancreatic stones in the cow. Calculi (black arrows) are identified within the major pancreatic duct. Distinct acoustic
shadowing (white arrows) is easily seen distal to the calculi. The image was taken in the right 10th intercostal space with a 3.5
MHz linear transducer.
Pancreatic fat necrosis

 Ultrasonography is an effective noninvasive means of identifying pancreatic lipomatosis
in cattle (Fig. B-105); however, disease confirmation is best achieved with pancreatic
biopsy.
Fig. B-105. Pancreatic hyperechogenicity in 2 cows with abdominal lipomatosis. Images were taken in the right 11 intercostal space
with a 3.5 MHz linear transducer. PV, portal vein.
Pancreatic abscess
 Pancreatic abscess it is rare and is identified as a mass lesion in the right cranial abdomen
with thick walls and hypoechoic contents, similar to other intra-abdominal abscesses (Fig.
B-106).
 It is difficult to differentiate pancreatic abscess from necrosis or tumor. Diagnosis is by
aspiration and culture; however, pancreatic abscesses may be sterile.
Fig. B-106. Ultrasonogram of the pancreas in a Holstein cow taken from the 10th intercostal space with a 3.5MHz linear transducer.
Hypoechogenic foci (abscess, A) can be identified within the right lobe of the pancreas (P). PV; portal vein, O; omasum.
Chapter6: Ultrasonographic Examination of the Urinary System
Introduction
 Diseases of the urinary system are less common than disorders of the gastrointestinal,
respiratory, musculoskeletal, and other systems. For this reason, and because signs of
renal disease may be subtle, the urinary tract is often misdiagnosed as a cause of illness.
Most practitioners use the gross appearance of urine, the evaluation of abnormal urine
constituents based on multiple reagent test strips, and the signs found on physical
examination as indicators of urinary tract disease.
 Vague illnesses that originate from the urinary system may require more ancillary data in
the form of complete urinalysis, serum electrolytes and chemistry, and complete blood
counts for diagnosis.
 Many diagnostic-imaging techniques can be used for the evaluation of the urinary tract.
However, certain radiographic diagnostic procedures, such as intravenous pyelography,
contrast cystography, and excretory urography cannot be performed because of their large
size.
 Ultrasonography, on the other hand, is applicable and valuable diagnostic information can
be obtained.
 Sonography supplements the clinical examination and clinicopathological analysis by
providing additional information on urinary tract diseases.
Kidneys
Imaging technique
 In large ruminants and horses, the right kidney is usually scanned transabdominally
providing sufficient penetration to image the entire kidney and to provide good resolution
for a thorough evaluation of the renal structure. From the lateral aspect of the body wall,
images in the dorsal and transverse planes are obtained. For this purpose, a small area of
hair is clipped and the site is prepared with alcohol. On the right side, this is just dorsal in
the right paralubmar fossa caudal to the last rib and in the last intercostal space.
 Examination is usually carried out using either 3.5 or 5.0 MHz linear or sector
transducers. Examination of the left kidney in cattle, buffalo, horses, and camels is usually
carried out transrectally using 5, 6, 7 or 8 MHz linear transducers.
 The animals are positioned in a standing position; after applying acoustic coupling gel, the
transducer is held parallel to the long axis of the animal for longitudinal images, and
perpendicular to the spine for transverse images. It is often easier to locate the kidneys if
one starts in the transverse plane, moving the transducer slowly in a cranio-caudal
direction.
Normal appearance
 The normal renal outline is smooth and well defined. Depending on the angle of the
ultrasound beam, the capsule may be seen as a hyperechoic line, and edge shadowing may
be seen. In all planes, three distinct areas can be recognized: the renal cortex, renal,
medulla and renal sinus. The renal sinus with its connective tissue and peri-pelvic fat is
seen as a complex hyperechoic structure. The medulla, surrounding the renal sinus, is
almost anechoic (Fig. B-107, B-108 and B-109).
 The interlobar and arcuate arteries between medulla and cortex are sometimes seen as
short linear echogenicities. Compared to the medulla, the cortex has a higher echogenicity.
The renal cortex appears to have a similar or slightly decreased echogenicity when
compared to the liver. The normal ureters are not identified. In contrast, renal veins and
arteries can be traced between kidney and aorta or caudal venal cava.
Fig. B-107. Ultrasonogram (transverse view) of the right kidney of a dairy cow imaged from the right paralumbar fossa. 1 = renal
cortex; 2 = medullary pyramid; 3 = renal sinus; 4 = renal veins and arteries; 5 = renal capsule; 6 = renal pelvis.
Fig. B-108. Transcutaneous ultrasonograms of the right kidney in 4 healthy camels. Images were taken from the right paralumbar
fossa. C = renal cortex; M = medullary pyramid; RS = renal sinus; RC = renal capsule.
Fig. B-109. Transrectal ultrasonograms (CS, left image; LS, middle and right images) of the left kidney in 3 healthy camels. C = renal
cortex; M = medullary pyramid; RS = renal sinus; RC = renal capsule; RW = ruminal wall; CS, cross section; LS, longitudinal
section
 In sheep, the kidneys are examined from the right paralumbar fossa by the use of a 5.0
MHz sector scanner; and they are viewed in both transverse and longitudinal sections. To
visualize the right kidney longitudinally, the transducer is always placed behind the last
rib high on the paralumbar fossa.
 The transducer is held slightly obliquely because the longitudinal axis of the right kidney
does not lie horizontally in most cases. To visualize the left kidney longitudinally, the
transducer is placed over the middle of the paralumbar fossa, parallel to the lumbar
vertebrae.
 Transverse ultrasonographic visualization of both kidneys is performed by placing the
transducer at right angles to the longitudinal axis of each kidney. The surface of both
kidneys is smooth. The centrally located hyperechogenic renal sinus is easily
distinguished from the surrounding hypoechogenic renal cortex and medulla.
 Ultrasonographically, the renal medulla consists of anechoic, circular, medullary
pyramids. The renal cortex appears uniformly gray and less echogenic than the renal sinus
(Fig. B-110).
 The renal hilus can always be visualized in the transverse image of the kidney.
Occasionally, the renal vein, the artery, and the ureter could be visualized in the region of
the renal hilus; however, they could not be differentiated from one another.
Fig. B-110. Normal sheep right renal ultrasonogram.

 In equines, both kidneys can be scanned transabdominally, and the left kidney can be
scanned transrectally in the adult horse. The right kidney is usually found in the right 14th
through 16th intercostal space, between a line drawn level with the dorsal and the ventral,
most aspects of the tuber coxae. This kidney is retroperitoneal, and is immediately
underneath the abdominal wall.
 This kidney can usually be visualized with a 5.0 or 3.5 MHz transducer in the adult horse.
The left kidney is located slightly more ventrally, medial to the spleen, and thus is further
away from the abdominal wall. This kidney is located in the 17th intercostal space and/or
paralumbar fossa, between a line drawn level with the tuber coxae and the tuber ischii.
Scanning this kidney in the adult horse often requires a 2.5 MHz transducer.
 The kidneys are normally the least echogenic organs in the abdomen, although normal
older horses often have renal echogenicity similar to or even increased over that of the
liver (Fig. B-111).
 Rectal ultrasonographic examination of the left kidney in the adult horse usually yields
superior images, and can be most successfully performed using a 5.0 - 10.0 MHz
transducer.
Fig. B-111. Normal equine right renal

ultrasonogram. (A) Renal
capsule (c), cortex (Cx), sinus
(s), pyramids (p), and
intrarenal vessels (v).
Ultrasonographic measurements of the kidneys include:

1. Length of the kidney (the distance between the cranial and caudal renal poles, measured in the
longitudinal plane).
2. Depth of the kidney (the distance between the ventral and the dorsal surfaces, measured in the
transverse plane at the level of the renal hilus).
3. Width of the kidney (the distance between the lateral and the medial margin of the kidney,
measured in the transverse plane at the level of the renal hilus).
4. Diameter of the renal sinus (measured from dorsal to ventral in the transverse plane at the
level of the renal hilus).
5. Circumference of three medullary pyramids.
Renal cysts
 Cysts may be solitary or multiple and may be uni- or bilateral. Sonographically,
cysts are usually round or ovoid structures with a smooth, thin, and well-defined
wall and anechoic content. The far wall is usually sharply demarcated, and distant
acoustic enhancement is seen.
 The latter two features are helpful for distinguishing solid but hypoechoic lesions,
such as lymphoma, from cysts. The latter remain anechoic if the gain settings of
the machine are increased, whereas hypoechoic lesions are seen to have internal
structure.
 Cysts may show edge shadowing and slice thickness artefacts, mimicking the
presence of sediment. In superficial cysts, assessment of the near wall may be
difficult due to reverberation artefact.
 Large or multiple cysts often distort the contour of the kidney, and may cause
displacement and distortion of the collecting system. Cysts may be heritable or
secondary to chronic nephropathy. Differential diagnoses for complicated cysts
must include renal abscess, hematoma, granuloma, and cystic neoplasia. These
often exhibit many, but only rarely all, features of a simple cyst (Fig. B-112).
Fig. B-112. Multiple renal cysts. The kidney has an irregular border and contains an anechoic round structure with a sharply
demarcated far wall border. There is an acoustic enhancement distant to the lesion and an edge shadowing at the lateral
borders of the cyst and kidney.
Collecting system, pelvis, and ureters
Hydronephrosis
 In normal animals, the renal pelvis does not retain fluid and is not visible sonographically.
The most commonly seen abnormality of the collecting system, pelvis, and ureters is
dilation, and ultrasound is a sensitive technique for investigating the potential causes.
Differential diagnoses include congenital anomaly, ureteric obstruction, pyelonephritis,
and diuresis following administration of intravenous fluids or diuretic.
 Ultrasonography is a useful aid for the diagnosis of obstructive urolithiasis. All parts of
the urinary tract must be examined for urinary calculi. In cows with unilateral
hydronephrosis, a massive dilatation of the renal sinus is usually found on ultrasonograms.
In particular, ultrasonography is especially helpful for the diagnosis of hydronephrosis of
the right kidney, which cannot normally be palpated transrectally. The ultrasonographic
appearance of the diseased kidneys was heterogeneous, similar to the descriptions in the
other reports of hydronephrosis. Dilatation of the renal sinus is the most common finding
followed by cystic changes within the kidney (Fig. B-113).
Fig. B-113. Ultrasonograms showing a normal kidney control bordered by arrows in A, and distended kidneys containing urine in
numerous multiple fluid-filled cavities in 4 cows (B, C, D, E and F). The renal sinus of the affected kidney is hypoechogenic
and the medullary pyramids are conspicuously small. Images are taken transrectally using a 5.0 MHz linear transducer
Pyelonephritis
 Pyelonephritis lesions may be detected unilaterally or bilaterally. The main
ultrasonographic findings are dilatation of the left or right ureter, cystic lesions in one or
both kidneys, and dilatation of the renal sinus. The renal sinus of the affected kidney is
often hyperechogenic; the medullary pyramids are conspicuously small, and have several
echogenic foci with acoustic shadows as well as multiple fluid-filled cavities in the
affected renal sinus/kidney. Ultrasonography is particularly helpful for the diagnosis of
pyelonephritis of the right kidney, which cannot normally be palpated transrectally, and
for assessing the condition of the right kidney in cases scheduled for left-sided
nephrectomy.
Renal calculi
 Renal calculi are usually easy to detect sonographically. Calculi are intensely hyperechoic,
with clean acoustic shadowing. Acoustic shadowing is an important feature for
differentiating calculi from blood clots, as the latter, although hyperechoic, do not produce
an acoustic shadow and their ultrasound appearance will change with time. In
questionable cases, the examination can be repeated a few days later.
 Calculi produce maximal shadowing if the highest possible transducer frequency is

chosen and the ultrasound beam is directed perpendicularly to the lesion in question,
which should be located within the focal zone of the transducer. Calculi are especially
easy to detect if they are associated with dilation of the renal pelvis. Small calculi,
especially if located within the renal parenchyma (Fig. B-114), may be difficult to
differentiate from the shadowing produced by the walls of the diverticula.
Fig. B-114. Large renal calculus (arrow) in a horse with chronic hydronephrosis.
Urinary bladder
Imaging procedure, normal and abnormal appearance

 The superficial position of the urinary bladder and the contrast produced by the anechoic
urine makes it ideal for ultrasound examination. Because identification of the empty
bladder is difficult and wall thickness is determined by the degree of distension, it is
recommended that the bladder be moderately full for the examination (Fig. B-115).
 Complete distension is not necessary or helpful. Ischemia, hemorrhage, cystitis and
rupture are potential risks for severe distension. The bladder appears as a fluid-filled
hypoechogenic organ whose circumference and wall thickness varies according to the
amount of urine inside it (Fig. B-116, B-117, B-118, B-119 and B-120).
Fig. B-115. Ultrasonogram of a normal bladder in a ewe: note the moderate bladder distension.
Fig. B-116. Ultrasonograms through the urinary bladder obtained transabdominally at the right ventral abdomen; the image is
taken with a 5.0 MHz sector transducer in calves affected with obstructive urolithiasis.
Fig. B-117. Ultrasonogram showing massive distension of the urinary bladder in a ram. The bladder wall appears as hyperechoic line.
The urine appears anechoic ram with leakage into the peritoneum (uroperitoneum). Image was taken with 5.0 MHz sector
transducer.
Fig. B-118. Same image in Fig. B-6-11 taken with 6.0 MHz linear Fig. B-119. Same image in Fig. B-6-11 taken with 8.0 MHz linear
transducer showing massive distension of the urinary transducer showing massive distension of the urinary
bladder in a ram. The bladder wall appears as hyperechoic bladder in a ram. The bladder wall appears as
line. The urine appears anechoic ram with leakage into the hyperechoic line. The urine appears anechoic ram with
peritoneum (uroperitoneum). leakage into the peritoneum (uroperitoneum).
Fig. B-120. Ultrasonogram of the urinary bladder in a male camel showing distension of the urinary bladder with leakage into
the peritoneum (uroperitoneum). The bladder wall appears hyperechoic. The urine appears anechoic (7.5MHz linear
scanner).
Cystitis
 Cystitis is the most common disease process involving the urinary bladder. Acute cystitis
usually causes no sonographic abnormalities. Long-standing and severe cystitis often
leads to diffuse bladder wall thickening, with a hyperechoic wall and irregular mucosal
surface, and is usually more pronounced cranioventrally, but may involve the entire
bladder wall in severe cases (Fig. B-121, B-122 and B-123).
 Polypoid cystitis usually is as wall thickening with multiple small nodules protruding into
the bladder lumen, but large polyps may be seen as pedunculated masses. Since bladder
wall neoplasia is more common than polypoid cystitis, the diagnosis has to be confirmed
with biopsy.
Fig. B-121. Ultrasonograms in 4 calves with a chronic cystitis. The entire wall of this distended bladder is thickened (1.15cm). In mild cases,
there is often no thickening, or only thickening of the ventral bladder wall.
Fig. B-122. Ultrasonograms of the urinary bladder in 2 camels with chronic cystitis. The entire wall of the bladder is thickened and
corrugated.
Fig. B-123. Ultrasonograms of the urinary bladder in a horse with a chronic cystitis. The entire wall of the bladder is thickened. Image
was taken during transrectal examination. Notice the corrugation of the bladder wall.
Bladder content
 Except for single, very small stones, cystic calculi are easy to detect sonographically
where they are seen as hyperechoic lesions with shadowing in the dependent portion of
the bladder. The amount of shadowing depends on the size of the calculus, the
composition, the transducer frequency used, and whether the sound beam is directed
perpendicularly to the surface.
 Occasionally, but only rarely, calculi may adhere to the bladder wall and can be mistaken
for bladder wall calcification. When agitated, sediment suspends easily, leading to
corpuscular echogenicities with no distinct distinguishable calculi.
 Floating echogenicities without shadowing may be seen where the urine contains cellular
debris, blood or fibrin (hyperechoic strands) (Fig. B-124).
Fig. B-124. Highly echogenic cellular urine is present in this goat. Because of the increased echogenicity of the
urine, the bladder wall is difficult to assess.
 Ultrasonographic examination of the abdomen has simplified the detection of either intact
or ruptured urinary bladder, and the presence of uroperitoneum.
 Ultrasonography should be considered the preferred imaging modality for the detection of
excessive peritoneal fluids and for the determination of its prognosis.
 The bladder is usually markedly dilated. In advanced cases of urine retention, the bladder
will be ruptured resulting in fluid accumulation in the abdominal cavity (Fig. B-125 and
Fig. B-126).
Fig. B-125. Ultrasonograms through the urinary bladder obtained transabdominally at the right ventral abdomen, the image is taken
with a 5.0 MHz sector transducer in calves affected with obstructive urolithiasis. Notice the numerous weak echoes in image
D., the ventral part of the urinary bladder.
Fig. B-126. Ultrasonograms obtained from the linea alba of calves with urine accumulation in the abdomen because of rupture of
the urinary bladder. The image was taken with 3.5 MHz sector transducer.
Ultrasonography in males with urethral obstruction

 In normal animal, there is scant peritoneal fluid that cannot be visualized during
ultrasonographic examination. Partial or complete urethral obstruction results in bladder
distension and, potentially, urine leakage into the abdominal cavity, and rupture of the
urinary bladder. The distended bladder appears as an anechoic area bordered by a bright
white (hyperechoic) line. The walls of the abdominal viscera appear as hyperechoic
(bright white) lines/circles. Free fluid, including blood-tinged urine, within the abdominal
cavity is visualized as an anechoic area. Fibrin tags, where present, are seen as
hyperechoic filaments within the anechoic fluid.
Renal biopsy
Renal biopsy is of high importance in animals with renal impairment. Prior to biopsy, and
under aseptic conditions, a small incision is made in the skin over the suggested biopsy site with
the point of a scalpel blade. Using a free-hand technique, a 14G × 150 mm spinal biopsy needle is
used. The biopsy needle is then advanced through the skin incision, and then under real-time
ultrasound guidance toward the renal parenchyma. During biopsy of the kidneys, advancement of
the needle is halted when the tip of the needle is seen to penetrate the renal capsule. The needle is
directed obliquely in an attempt to sample cortical tissue only, and to avoid the renal medulla,
renal pelvis and hilar, and renal vessels. When the needle is considered to be in the correct
position, the plain stylet is withdrawn and a notched part is inserted and advanced 1 cm into the
renal cortex beyond the renal capsule. Always the needle could be identified on the ultrasound
within the renal cortex (Fig. B-127) while the specimen is being obtained, thus confirming the
location of the biopsy. Both the needle and forked stylet are then removed with a sample of
hepatic or renal tissue.
Fig. B-127: Renal biopsy in a camel. The needle is clearly visible within the renal cortex. Ds = dorsal; Vt = ventral.
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Part III
Female and Male Reproductive Ultrasonography
By
Ahmed Ali (BVSc, MVSc, PhD-Germany)
Chapter 1: Ultrasonography of the Cardiovascular System
Introduction
The use of diagnostic ultrasonography for the evaluation of the reproductive tract and ovarian
structure is growing rapidly.
B-mode real-time ultrasonography is an accurate, reliable, non-invasive and non-time
consuming method for pregnancy diagnosis, fetal quantification, and gestational age
determination in farm animals. In addition, ultrasonography is a method of choice for detecting
pathological conditions of the genital tract such as pyometra, hydrometra, metritis, mummified
fetuses, and fetal mortality.
Visualization of the ovaries can give extra information about the follicle population, the
presence of functional corpora lutea, follicular and luteinized cysts, haematomas in the ovaries.
Ovarian responses to hormonal treatment and abnormalities can also be detected by
ultrasonography.
Interpretation of the ultrasound view of the reproductive tract

Proper interpretation of the echoes on the ultrasound screen is crucial. Examples for
Interpretation of the ultrasound images of uterine contents and ovarian structures are drawn in
Figs. (C-1, C-2, C-3). Artifacts are especially common during imaging of the reproductive tract.
Allantois Amnion Pus
Fig. C-1: Interpretation of the ultrasound gray image of uterine contents.
113
Follicle cyst Corpus Haemorrahgicum Corpus Luteum Regressed CL
Fig. C-2: Interpretation of the ultrasound gray image of ovarian structures.
Fluid-filled cavities Lutein tissues
Follicle Theca Cyst Follicle Lutein cyst Cystic Corpus Luteum Corpus Luteum
Fig. C-3: Interpretation the ultrasound images of the ovarian cysts and corpus Luteum.
Female and Male Reproductive Ultrasonography 115
Chapter I: Female Reproductive Tract Ultrasonography
Ultrasonography of the reproductive tract of the mare
1,2: vulva lips

3: vesibulum
4,5: hymnal ring
6: vagina
7: fornix
8: cervix
9: body of uterus
10: uterine horns
11: broad lig.
12,13: fallopian tube
14: ovary
(www. ansci.wisc.edu)
Technique of examination
Before ultrasonographic examination, the reproductive organs should be firstly palpated
thereby facilitating the location of the organs and the exact positing of the probe to make certain a
rapid and precise examination (Fig. C-4). Feces and gas hamper the transmission of the ultrasound
waves. The fecal matter absorbs the sound waves resulting in the appearance of black strips in the
depth of the image, then the rectum must be evacuated and the probe then introduced through the
anus. The probe should be covered from dorsum by the operator’s hand to protect the rectum from
injuries. With increased experiences, it is possible to determine the position of the organs and the
probe’s orientation by recognizing typical images on the screen. It is usually not necessary to
manually position the organs in preparation for an ultrasound examination.
The urinary bladder (land mark of the pelvis) should be depicted firstly (Fig. C-5). The neck
of the bladder widens over the cranial pelvic edges to join the body of the bladder. The mare’s
urine can vary greatly in its echogenic picture. The ultrasonic image differs from an anechoic to
strongly echoic in the case of extreme gluey urine. After visualizing the urinary bladder the
ultrasound probe is advanced cranially until the uterus appears on the screen. The probe is placed
dorsally on the uterus at the level of bifurcation; from here, the probe is rotated laterally along the
uterine horn until the ovary is visualized and then back to the opposite side to visualize the other
ovary (Fig. C-6). In this method, the uterine horns are scanned slice by slice, each slice represents
a cross section through the uterine horn. The uterine body and the cervix are generally viewed in
longitudinal section.
Fig. C-4: Topography of the mare' genital tract, (www. yallambeestud.com).
Uterine horn
UB
Fig. C-5: Urinary bladder (UB) as a guide for genital tract in mare.
Fig. C-6: Technique of ultrasound examination of mare’s genitalia in a systemic manner, (Ginther, 1986).
Ovarian structure in the mare
Follicles
The follicles give in the ultrasonic images the characteristic feature of fluid filled structures
(anechoic or black), (Fig C-7). The anechoic nature of the follicle is resulted from the lack of the
reflection of sound waves as they travel through the relatively cell free, clear follicular fluid. The
shape of follicles varies from circular, oval, and irregularly polygonal to nearly angular. These
variations in shape are the result of differences in pressure between neighboring follicles, corpora
lutea or even the ovarian stroma itself. The follicular wall is hyperechoic and thin. Bright images
are seen behind larger fluid filled vesicles (enhancement artifact). Using ultrasound at frequency
of 5.0 MHz follicles of 3 mm are detectable with relative ease.
Approximately 192 hrs before ovulation, dominant estrous follicles have a diameter of
about 25 mm. They then grow at 2 to 2,5 mm per day and reach their maximum diameter of 41 to
45 mm at 24 to 48 hr before ovulation. No further growth occurs during the last 1 to 2 days before
ovulation. The dominant follicles are round 3 or more days before ovulation, during the days until
ovulation the estrous follicles will change to a more oval or irregular shape. The ultrasonic shape
and size of a follicle can be utilized to help predict the time of an impending ovulation. If the
largest follicle shows an irregular shape, at least 40 mm in size and possibly is shown to have
stopped growing for some time, one should expect ovulation to occur very soon (Fig C-8). An
ovulation can be recognized ultrasonically when a follicle that was present a short time ago cannot
be found at a subsequent examination. Ovulation process takes seconds to minutes. The wall of
the follicle appears to be folded inwards; the follicular cavity is irregular in shape and sometimes
it contains small quantities of residual fluid.
After ovulation, it is possible to determine the disappearance of the preovulatory follicle by
rectal palpation. Sometimes, however, the symptoms of estrus diminish while the preovulatory
follicle seems to persist. It is difficult to distinguish a persisting follicle from a firm corpus
haemorrhagicum by rectal examination alone. A corpus haemorrhagicum may be recognized by
its homogenous grey, echogenic structure. The content of a persisting follicle, on the other hand,
is clear. When luteinization occurs thickening of the wall is discernable.
Fig. C-7: Follicle (round) of 40 mm in diameter during estrus phase.

Fig. C-8: Follicle (irregular) of 45 mm in diameter before ovulation.
Corpus luteum
The corpus luteum in the ovary cannot be determined by palpation, because of its typical
location. However, by using ultrasonographic examination the corpus luteum can be visualized in
most cases. Luteal tissues are shown on ultrasound in different gray tones; with the surrounding,
ovarian parenchyma is more echogenic. The shape of a corpus luteum is irregular in many cases.
Corpora lutea are relatively reliably detectable from their formation until mid of the cycle,
thereafter they become less distinct. The site of the development of a corpus luteum can be
recognized by its ultrasonic echogenicity within the first 24 hrs after ovulation. These intense
reflections originate from the hemorrhage into the follicular lumen which occurs after ovulation.
The hemorrhagic area of young corpora lutea remains very echoic for the first 3 to 4 days
following ovulation (Fig. C-9, 10). Two kinds of corpora lutea can be distinguished during the
diestrus in mares: non-homogenous corpora lutea and compact corpora lutea. The non-
homogenous one consists of two distinct zones of differing appearance: a hyperechoic peripheral
edge and a central less echoic core area, after ovulation, the entire cross sections of almost all
hemorrhagic copora lutea are echoic (Fig. C-11). Only after a few days, the hypoechoic central
area is distinguished from the more echoic peripheral area. As the cycle progress, the echoic areas
enlarge. Solid corpora lutea have a homogenous echogenicity across their entire sectional surface
(Fig. C-12). Once conception has occurred that the primary corpus luteum of pregnancy remains
detectable during the course of early gestation. The accessory copora lutea of pregnancy which
developed between days 40 and 60 of gestation can be demonstrated by ultrasonography. In the
beginning they show a narrow peripheral edge which surrounds the trabecular hypoechoic central
area. During the further course of pregnancy the central less echoic area becomes smaller, while
the hyperechoic luteinized wall grows thicker.
Fig. C-9: Corpus haemorrahgicum just after ovulation.
Fig. C-10: Corpus haemorrahgicum 4 days after ovulation.
Fig. C-11: Non-homogenous corpus luteum at day 10 of estrous cycle.

CL
Fig. C-12: Homogenous compact corpus luteum (CL) at day 10 of estrus cycle.
Luteinized follicles
Anovulatory follicles develop into a dominant follicle, but fail to ovulate. Often they grow
to large diameters of 10 cm. Some of them develop into hemorrhagic follicles, whereas others
show clear signs of luteinization. During estrus the sonographic appearance of anovulatory follicle
resembles that of normal follicle. Hyperechoic reflections will appear shortly after the expected
time of ovulation. These reflections traverse the hypoechoic follicular lumen in the form of
networks. These echoes represent the onset of luteinization, or may originate from the bloody
follicular contents such as that occurs in hemorrhagic follicles. When anovulatory follicles show
these phenomena, estrus is over in most cases and the mare refuses the stallion. The hyperechoic
wall will progressively become wider, while the central hypoechoic area shrinks. Some of the
ovulatory follicles therefore seem to luteinize into structures similar to corpora lutea. During the
course of development of the luteinized structure, the plasma progesterone concentrations reached
the expected levels and estrus occurred at the normal time. Similar pictures could also be seen
during early pregnancy.
Hemorrhagic follicles
These are follicles which develop into hemorrhagic follicles or follicular hematomas. The
hemorrhage takes place by diapedesis into the follicular lumen. The mesh of reflection that
typically develops in the lumen of a luteinizing anovulatory follicle fails to develop in this type of
anovulatory follicle. The diameters are usually only a little larger than those of mature
preovulatory follicles. In rare cases, ovarian hematomas with a diameter of 20 cm and more and a
weight of several kilograms are encountered. On ultrasound, such hematomas can appear as cystic
structures with evenly scattered snow-like echoes in their lumina.
First ovulation in seasonal breeding mare

In a number of cases, it may be necessary to ascertain early in the mating season whether a
mare is cyclic or not. If manual examination is made exclusively, it may be difficult to distinguish
between a mare in proestrus and one that has not yet ovulated. Both may show weak signs of
estrus, and the diminishing corpus luteum of the cyclic mare cannot be palpated. Follicular
activity is not a deciding factor. When examined again, ten days later, the cyclic mare will have
ovulated. Should no corpus luteum be found, and the largest follicle is smaller than 20 mm, the
mare is anovulatory.
Anestrous
When a mare fails to show signs of estrus during breeding season, ultrasound scanning
should be used to determine the presence of a corpus luteum. Repeated examination will reveal
whether the corpus luteum is persistent. Moreover, ultrasonography gives detailed information
about follicular activity.
Uterine structures in the mare
Non-pregnant uterus
A non-pregnant uterine horn is seen in cross-section as a round to oval structure. The
structure of the uterus is homogenous during anestrus and diestrus (Fig. C-13). A distinct layering
cannot be recognized. Around the time of estrus a clear distinction between areas of differing
echogenicity can be observed (Fig. C-14). The ring like structure in the area between endo- and
myometrium which lies concentrically oriented to the outer, peritoneal wall of the uterus is now
very prominent. From this zone hypoechoic strips run towards the center of the lumen where they
meet to form a star (spoke-wheel) pattern. This pattern is caused by the endometrial folds which
bulge towards the center of the uterine lumen. This wagon wheel pattern of the uterus is typical of
estrus and can clearly be seen in about 50% of all estrous mares. It is associated with the
estrogenisation during the estrus, and become apparent few days before ovulation, and then
gradually weakens until it disappears 2 days after ovulation.
Small amounts of free fluid may be seen during estrus in the uterine lumen. Larger fluid
accumulation of a physiological origin will not be found in the non-pregnant uterus. Immediately
after mating, the ejaculate can be seen in the uterine lumen. Accumulation of large amount of
fluid in the lumen of the diestrus uterus is an indication of endometritis.
Fig. C-13: Cross section of the uterine horn (diestrus); there is no fluid retention and no demarcation layers.
Fig. C-14: Cross section of the uterine horn (estrus): fluid retention and wheel like appearance of the uterine folds.
Pregnant uterus
The embryo becomes visible when it forms a fluid filled vesicle, large enough to be
recognized as a round, anechoic sphere on the ultrasound monitor (Fig. C-15). Depending on the
quality of the scanner, this is first possible between days 9 and 13 of pregnancy. On the day 10 the
vesicle measures 4-7 mm and will be detectable in as many as about 70% of the mares. On the
day 11 it reaches 6 to 9 mm and will be visible in nearly all mares. Around day 12 the conceptus
has a diameter of 10 to 12 mm.
By day 14 the embryonic vesicle has a diameter of 14 to 19 mm. It is now large enough to
make accurate and reliable positive and negative diagnosis under field condition. The shape of the
embryonic vesicle is spherical and embryo proper is not yet visible. Breed related differences in
the size of the embryonic vesicle are negligible during the first three weeks of pregnancy.
The conceptus moves from one horn to the other, and through the uterine body several
times every day and may be found in different positions within the uterus during successive
examinations. From days 9 to 11 the embryos was found in the uterine body in 60% of the cases,
from day 12 to 14 in 30% of the cases and thereafter only rarely. The positional changes of the
conceptus appear to be caused by the contractions of the uterine wall and can be controlled by the
conceptus itself. The careful sonographic examination of the corpus uteri during this stage of early
pregnancy is of particular importance. The preferred site of implantation lies just next to the
bifurcation in one of the uterine horns.
The conceptus has a strictly spherical shape until day 15 of gestation, thereafter it first
becomes ovoid until day 17 and, between days 18 and 21 it is usually pear shaped, after which it
assumes an irregular shape (Fig. C-16, 17).
There are many criteria which can be used to distinguish the early embryonic vesicle from
pathological conditions such as endometrial cysts, the secretion in case of endometritis or
embryonic death. At this stage the intact conceptus is a round spherical vesicle clearly visible and
contrasted against the echoic uterine wall. There are reflections inside the vesicle so that its fluid
contents appear black.
Fig. C-15: Amniotic vesicle (round shape) - mare, 20d pregnancy.
Fig. C-16: Amniotic vesicle (irregular shape)- mare, 23d pregnancy.

Fig. C-17: Amniotic vesicle (pear shape), mare, 26d pregnancy.
For several reasons, the time from days 15 to 18 can be considered most appropriate for
early sonographic pregnancy detection; at this stage it is no longer difficult to demonstrate the
early embryonic vesicle. Not only are twin pregnancies easy to recognize at this time period but it
is quite favorable for a timely intervention where indicated. In case of detection of non-pregnancy
the ultrasound examination can be used to asses follicular development, because the following
estrus should be imminent. Once an early pregnancy has been diagnosed during the first few
weeks of gestation, it is useful to reexamine the mare at about day 30 of pregnancy so that a
possible embryonic death can be detected. Since embryonic death can also occur after day 30 of
gestation another examination is recommended between days 50 and 60 so that all embryonic
losses can be detected.
The embryo proper is detectable on about day 21 for the first time near the floor of the
vesicle. It is firstly visible as a hyperechoic spot on the floor of the embryonic vesicle. From day
21 to 40 the embryo follows a characteristic ascent within its vesicle (Fig. C-18). Ventral to the
embryo the allantois starts to fill up, lifting the embryo. While the yolk sac above the embryo
initially occupies the bulk of the early conceptus it now shrinks over the next few days. The ratio
between the sizes of the two embryonic structures gradually moves in favor of the allantois until
the yolk sac has disappeared by day 40. The embryo appears to be suspended by the hyperechoic
membrane formed by allantois and yolk sac, and floats inside the anechoic embryonic fluid. The
majority of embryos commence their ascent between days 22 and 25. On day 27 they are still
suspended in the bottom third of the vesicle, by day 30 in the center and by day 33 in the top third
of the vesicle.
On day 25 the embryo is about 5 mm long. It grows by about 1 mm per day to reach 12 mm
by day 30, 17 mm by day 35, and 22 mm by about day 40.
The embryo heart beat can be detected around day 26. The heart beat is an important
criterion for the assessment of embryonic viability, and for the exclusion of a pathological
pregnancy.
EM
Fig. C-18: Ascending of the embryo (EM) within the amniotic vesicle, mare, d 30 pregnancy.
EM
Fig. C-19: The embryo (EM) at the top of the amniotic vesicle, mare, 45d pregnancy.
Tthe embryo reaches its highest position within the embryonic vesicle around day 40. From
here it gradually sinks, suspended by its umbilical cord, back down to the floor of the vesicle
(Figs. C-19, C-20). After this time, movements of the fetus can be observed frequently.
The fetus has a crown rump length of 25 mm on day 45 of gestation and grows to a length
of 40 mm by day 60. From day 50 to 60 a penetration depth of 10 cm is inadequate to show the
vesicle in its entirety.
Twin pregnancy
The incidence of twin pregnancy ranged from 6% to 15% between days 13 and 21 of
pregnancy, and from 1% to 6% if the examination is performed later.
The diagnosis is likely between days 12 and 16. Two-sided located twin pregnancy is not
difficult to recognize. Difficulties are encountered in cases of ipsilateral twin pregnancy where
both conceptuses lie close together in the same horn (Fig. C-21). A very significant cause of error
is that the examiner is satisfied with the detection of one embryonic vesicle and neglects to
examine the remaining section of the uterus for the other vesicle. In unilaterally fixed adjacent
twins, an embryonic mortality is likely between days 17 and 29. The resorption of one membrane
of a twin is more likely than that of both. Bilateral fixed twins continue to develop in the majority
of cases and lead to abortion during the advanced stages of pregnancy.
When twins of clearly differing sizes are diagnosed until day 16 of gestation, the possibility
of a spontaneous resorption should be considered. Intervention may be postponed until 2 to 3 days
later, when it is evident from the follow up examination that both embryos have continued to
develop since the previous examination. If a bilaterally fixed twin pregnancy is first detected after
day 16 an intervention is indicated, because it is likely that both embryos will persist. Since a
spontaneous resorption is more likely in unilaterally fixed twins after day 16 an intervention can
be postponed for some time.
Fetus
Fig. C-20: Descending of the fetus within the vesicle, mare, 60d pregnancy.
Fig. C-21: Twine pregnancy, mare, 35d.

Just as a twin pregnancy has been reduced by the crushing of one vesicle the successful
elimination of the one vesicle and the further development of the other should be monitored.
Where an embryo has been eliminated by crushing it before day 20 the survival chance for the
second conceptus is good, but in later cases one must expect the second embryo to die. In
advanced pregnancy it is difficult to diagnose twin pregnancies by transrectal ultrasonography.
Hence the manual reduction of a twin pregnancy is usually not successful after day 20 to 25,
the possibility of the elimination of one conceptus by controlled puncture was considered. It
appeared promising to puncture conceptus under visual control of a vaginally introduced
ultrasound probe. The punctures are performed after the vestibulum and vagina are prepared
aseptically and the mare is sedated. For the sake of sterility the instrumentation is covered in a
sterile plastic sleeve. The tube of the instrument with the attached puncturing device is introduced
into the vagina in the same manner as a tubular speculum. It is pushed against the anterior vaginal
wall and one hand is ntroduced into the rectum to hold the uterus caudally and to fix it against the
ultrasound probe. Once the image of the conceptus is aligned with the puncture direction of the
needle the plastic sleeve is penetrated by the puncture needle when the trigger is pilled. It is
possible to aspirate fetal fluid through the needle.
Fetometry
After day 60 of pregnancy, significance of transrectal ultrasonography for diagnosis of
pregnancy in the mare decreases. At this stage the emphasis of the value of the ultrasound shifts
towards fetal diagnostics. Sizes determined by fetometry can be used to assess gestational ages in
cases where uncertainty exists about the exact service date. Abnormal pregnancy can also be
made by this manner.
The technical difficulties associated with the ultrasonic examination of equine fetuses
depend on the stage of gestation. In about one half of the mares examined between day 80 and
100 of gestation the fetuses lay outside the range of the ultrasound waves. At this stage the
relatively small fetus had often descended cranioventrally into the uterus bulging far beyond the
pelvic brim. From the 4th month it becomes increasingly easier to reach some parts of the fetus so
that only 10 to 20% of all fetuses between the 5th and 11th months of gestation remained beyond
reach. The availability of individual fetal parts for ultrasonic examination also depended heavily
on the stage of gestation.
The eye is the fetal organ which is most frequently available for fetometrical assessment
during the entire course of gestation. The largest diameter of the eye increases approximately in a
linear fashion as pregnancy progresses (Fig. C-22).
The size of the stomach can be measured by orientating the ultrasound probe to show the
image with the greatest length of the stomach. Now the largest inner diameter of the hypoechoic
lumen of the stomach can be measured (Fig. C-23). Other fetal parts can be demonstrated
beginning at day 90 of pregnancy, (Figs. C24-C27).
Fetal sexing
This depends on that the location of the genital tubercle between the hind legs must be
determined. The embryonic genital bud differs into penis and prepuce in the male fetus and into
clitoris and vulva in the female fetus. During fetal development the genital tubercle migrates from
its origin between the hind legs cranially towards the umbilicus in the male and caudally towards
the tail in the female. By determining its position from about day 60 of gestation the sex of the
fetus can be determined. In both sexes the genital tubercle consists of a bilobular hyperechoic
structure. The optimum time for transrectal ultrasonographic sex determination in equine fetuses
appears to lie between days 60 and 70 of gestation.
In contrast to the situation in the bovine fetuses, it has not been possible to determine the
sex of equine fetuses by sonographic imaging of the scrotum. One reason for this is that the testes
descend much later into the scrotum. Therefore, the depiction of the scrotum and testes cannot be
used to differentiate between the sexes of equine fetuses.
Fig. C-22: Fetal eye (E), and lens (L), mare, 150d pregnancy.
Fig. C-23: Fetal stomach, mare, 155d pregnancy.

Fetal liver
Fig. C-24: Fetal liver, mare, 90d pregnancy.
Heart
Fig. C-25: Fetal heart and thoracic cavity, mare, 100d pregnancy.
UB
Fig. C-26: Urinary bladder (UB) of the fetus, mare, 115d pregnancy.
Intestine
Fig. C-27: Fetal intestine, mare, 90d pregnancy.
Uterine pathology
An imperative characteristic indicating the viability of a conceptus is the anechoic nature of
the fetal fluid. Embryonic death occurs up to 15% of all pregnancies, between days 10 and 50. In
the case of a resorption slight to moderate reflections will appear relatively soon within the fluid
of the embryonic vesicle. The interface between the embryonic vesicle and its surrounding is
smooth in the case of intact pregnancies. When this line becomes wavy, it may serve as an
indication that an embryonic death is imminent. In the intact pregnancy the conceptus remains
strictly spherical until day 15 of gestation. If the embryonic vesicle assumes any other shape
before this day it should be suspected to die. During later stages a change of shape can no longer
be used as a reliable indicator. The absence of heart beat is the most reliable sign for embryonic
death. In the intact embryo the heart rate is usually above 150 beats per minute. Another
indication that an embryonic death might be in progress is the inadequate size of the vesicle
(small-for-date) due to the subnormal volume of embryonic fluid. An embryonic resorption
occurring during the first 3 weeks of gestation usually runs a rapid course.
Absence of signs of estrus and the manual determination of an increased tonus on the uterus
may indicate pregnancy. However, these same findings may also be present in the case of early
embryonic death followed by persisting corpus luteum. After a late mid-cycle ovulation too, the
mare will not show signs of estrus at the expected time while the tonus on the uterus will be
increased. The differentiation between pregnancy and these forms of pseudopregnancy can only
be made with the help of echographic examination aimed at detecting the presence or absence of
an embryonic vesicle.
Accumulations of fluid inside the uterine lumen especially during diestrus are the very
characteristic of mare suffering from chronic endometritis. Fluid accumulations found during
estrus may be physiological, but it may also be an early indication of endometritis in many cases.
Whenever fluid secretions are found in the uterus during diestrus they should be regarded as
abnormal. The outline of the fluid accumulation in endometritis cases is typically a stellate shape
in a transverse section. The interface between the secretion and the surrounding uterine wall is
wavy. A typical feature of the uterine secretion in the case of endometritis is the increased
echogenicity of the fluid. It should be pointed out that amniotic fluid can also be echoic during the
2nd and 3rd trimesters of gestation. This also applies to the allantoic fluid during the last trimester
of pregnancy. The sonographic differentiation between the secretion of an endometritis and other
fluid types in the uterus such as placental fluid or that contained in endometrial cysts, must be
undertaken in conjunction with the assessment of other criteria, such as the echogenicity of the
fluid, its intra-uterine position, and its shape. The most suitable time for the ultrasonic diagnosis of
endometritis appears to be during the mid to late diestrus period.
Pyometra is considered a predominantly severe form of endometritis. Its ultrasonic image
features an extreme dilatation of uterus. Through this, the endometrial folds are stretched and the
interface between the uterine contents and the wall is smooth. Within the secretions of pyometra
there are usually intensive reflections which increase in density ventrally (Fig. C-28). The
ultrasound image of the urinary bladder can look much like that of a pyometra.
Mucometra is occasionally diagnosed in mares with an imperforate hymen. Most
commonly the diagnosis is made in young fillies. After the onset of ovarian and uterine cyclic
activity during puberty, the usual outflow of secretion from the genital tract is prevented by the
persistent hymen. This then leads to the accumulation of the mucous in the vagina and uterus.
Apart from typical findings such as the protrusion of the hymen from the vulva or the rectally
palpable enlargement of the uterus, the retained fluid can also be demonstrated sonographically in
several sections of the uterus. The ultrasonic diagnoses of mucometra are based on similar criteria
as are used for a pyometra.
Endometrial cysts are classically found in mares over 10 years of age. In this age cysts can
be found up to 25% of all mares. The cysts can be lymphatic or of glandular origin. Endometrial
cysts can be single or multiple. They can occur in both, the uterine body and uterine horns. It
seems possible that the cysts can affect the fertility of the mare. They do not, however, present an
absolute obstacle to the establishment of a pregnancy, because many pregnancies have been to
develop quite normally in the presence of endometrial cysts. In isolated cases, where the cysts are
particularly large or numerous, they appear to cause embryonic mortality by interfering with
normal implantation process of the embryo. Ultrasonically, cysts look like fluid filled vesicle with
a shape that can vary from spherical to long and oval (Fig. C-29). Their lumen can consist of a
single cavity, or it can be divided into several cavities. The cyst fluid, which is lymphatic fluid, is
anechoic and looks virtually black on ultrasonography. The size of these cysts can vary from a
few millimeters to several centimeters. Some cysts ranging in size from 10 to 30 mm can, at time,
be difficult to distinguish from day 10 to day 25 of pregnancy. From week 4 of pregnancy the
differentiation is easier, because the embryo is exhibiting a beating heart. A spherical shape, a
diameter consistent with the last reported service date, and a central position in the uterine lumen
are all symptoms favoring the diagnosis of a conceptus. Mobility of the vesicle or the detectable
presence of a heart beat inside the embryo will both confirm pregnancy. The mobility of the
embryo is usually evident until day 15 or 16, and can be observed in most cases by scanning the
vesicle for a few minutes. Indication of a cyst includes an irregular or oval shape, the presence of
several compartments within their lumen, or their multiple occurrences in the uterus. The vesicle
that lies eccentrically in the uterus should be viewed as cysts. Further indications that a detected
vesicle may be a cyst include a discrepancy between the observed and the expected diameter of
the vesicle, or its failure to grow in size. If there is still doubt about the identity of a vesicle, a
repeated examination after a few days is indicated. If the mare is pregnant, there will be a
detectable increase in the size of the embryonic vesicle by the time of the next examination.
Pus
Uterine
horn
Fig. C-28: Pyometra (accumulation of pus in the uterine horn), mare.

Ut. horn
Fig. C-29: Uterine cyst (arrow), single and eccentric, mare.
Ultrasonography of the reproductive tract of the Cow and Buffalo-cow
(www. ansci.wisc.edu)
In the cow and buffalo the ultrasonic examination is carried out in a way similar to that of
the transrectal palpation. The internal genitalia are trans-rectally palpated in the usual manner; the
probe is advanced cranially along the rectal floor. The vestibulum and vagina are only weakly
identifiable. The urinary bladder is the easily recognizable structure in the pelvis. It produces the
typical image of a hollow organ containing hypoechoic fluid and expands craniovetrally to form
the body of the bladder. Ventrally to the bladder, the pelvic floor can be seen. Its bony
components are evident as very bright, a few millimeters thick structures. The cervix of the non-
pregnant cow can be found at the level of the urinary bladder. The cervical structures that can be
identified include the cervical rings and a central, hyperechoic line which represents the cervical
canal. Immediately cranial to the cervix, usually in the midline, appear the body and horns of the
uterus. Occasionally, the uterus can also be found lateral to the urinary bladder. In the case of a
linear array, the probe is now swiveled from side to side to produce longitudinal images of the
uterus (Figs. C-30, C-31). When using a sector scanner, the operator can turn the beam through 90
degrees and thus change the scanning plane from longitudinal to transverse in relation to the body
axis. In this manner transverse sections of the uterus can be obtained. After scanning the uterus,
the probe can be rotated further laterally in order to visualize the ovaries. Care should be taken to
allocate each identical ovary to the correct side. The resolution of ultrasound at a frequency of 5.0
MHz is high enough to identify vesicular structures with a diameter of 3 to 5 mm. At the lower
frequencies of 3 to 3.5 MHz vesicles of 6 to 8 mm can be seen. To further increase image quality,
7.5 MHz ultrasonography can be used. Sound waves at this frequency provide a marginally better
resolution than that obtained with 5 MHz. The penetration depth of sound waves at 7.5 MHz is,
however, only 4 to 5 cm. For this reason the use of high frequency ultrasonography is restricted to
the examination of structures that are extremely close to the probe. Sound waves of 5 MHz
penetrate about 8 to 10 cm, thus allowing the examination of the ovaries and uterus during early
gestation. Since ultrasound at 3.5 MHz penetrates 12 to 15 cm, or deeper, it can be very usefully
applied in the later stages of gestation, or in cows with pathologically enlarged genitalia.
Fig. 30: Reproductive tract, cow.

Uterine horn
Fig. C-31: longitudinal ultrasonic view of uterine horn of non-pregnant cow.
Ovarian structures in the cow
Follicle
The follicles are characterized by the anechoic circular area of the follicular lumen (Fig. C-
32). The fluid content usually gives no reflection. The wall of a follicle can rarely be identified.
The shape of the follicle is usually round. Follicles with a diameter of less than 2 mm are too
small to be detectable. After ovulation has taken place, the ovulation depression or any other sign
of ovulation – except the disappearance of the large hypoechoic follicular structure – cannot be
detected. During early metestrus, the echographic image of the ovary corresponds to that of an
ovary without any significant functional structures.
The average diameter of the cavity of the estrus follicle at the time of standing heat is 15
mm (range 10 to 20 mm). Most estrus follicles reach their maximum size 36 hrs prior to
ovulation.
Blood vessels may be confused with ovarian follicles (Fig. C-33). Extended blood vessels
are seen during the luteal phase as a result of an increased blood flow to the corpus luteum. They
can be identified by moving the transducer: blood vessels can, unlike follicles, be traced during
scanning over a longer distance and are generally seen on the border of the ovary, in the ovarian
hilus, and around the corpus luteum.
Ovarian follicular growth in cattle occurs in wave like patterns. At the time of ovulation
another follicle is grows to develop into a dominant follicle, to grow further during metestrus, and
to reach its maximum diameter during the early luteal phase. Shortly after this diestrus follicle has
reached its maximum diameter, the second follicular wave starts and another dominant follicle
develops. In the case of a 2-phase follicular cycle this one will terminate in ovulation. Some cattle
show a 2-phase, others a 3phase pattern of development. In a 3-phase follicular development the
second dominant follicle also regresses and a third follicle develops into the estrus follicle.
Echogenic picture of the ovarian follicle in buffaloes is similar to that of cows, but it is yet
smaller in size (range 10 to 15 mm).
Fig. C-32: Ovarian follicle (round 14 mm), cow.
Ovary with cl and sf Blood vessels
Fig. C-33: Blood vessels in adjacent to ovary containingcorpus luteum (CL) and small follicle (left)
Corpora lutea
The corpus luteum appears as a grey round or oval structure, and well demarcated from the
remaining structures on the ovary (Fig. C-33). Corpora lutea with cavities, so called cystic corpora
lutea, can also be diagnosed by ultrasonography. In a corpus luteum with a cavity an echoic rim of
tissue, a few millimeters thick, surrounds a central anechoic fluid accumulation (Figs. C-34, C-
35). Frequently, the cross section of a corpus luteum contains a narrow, hyperechoic zone in the
center. Immediately following ovulation the developing luteal tissue cannot yet be recognized.
The young corpus luteum only becomes sonographically detectable 2 to 4 days post-ovulation.
Corpora lutea have a mean width of 14 mm and a mean length of between 18 and 21 mm when
they first become detectable on the third day after ovulation. Then they grow 1 mm in width and 2
mm in length per day, and reach their maximum size of about 20 x 30 mm by day 8 to 10 post
ovulation. After luteolysis has begun the largest diameter of the corpus luteum rapidly falls to be
23 mm. At a frequency of 5 MHz, corpora lutea are reliably detectable from their early
development to the end of diestrus. The gray scales of the corpora lutea of different ages vary very
little and cannot be employed for diagnostic purpose. At the same time, corpora lutea of
pregnancy cannot be distinguished on the basis of their echogenicity from those of the cycle. The
cavities inside corpora lutea are usually oval, occasionally round, and nearly always centrally
positioned inside the gland. The largest diameter of the cavities usually varies from mere
millimeters to 1.5 cm. The echogenicity of the cavities is similar to that of follicles. Slight
reflections can occasionally be seen inside the cavity’s fluid. The luteinized wall is used to
differentiate cystic corpora lutea from ovarian follicles. As during the estrous cycle, cystic corpora
lutea can also be found during the first weeks of pregnancy. The fertility of animals with a cystic
corpus luteum is the same as that of cows with the solid type of the corpus luteum. With the aid of
ultrasonography the number of corpora lutea on an ovary can be determined quite accurately. In
this manner the success of a superovulation attempt can be assessed, and a number of embryos
that could be harvested can be estimated. The cavity in cystic corpora lutea reached its largest
diameter between days 8 and 10 of the cycle. Afterwards they decreased in incidence and size
with time. Until day 10, one third to a half of all corpora lutea in normal cycles contain a
sonographically detectable cavity. After this time the incidence of cystic corpora lutea is
decreased by 3 to 4% per day so that less than one third of all luteal glands contain cavities by day
13. The cystic forms of luteal glands are 1 to 3 mm longer than the compact forms. Studies
completed so far on the endocrine status of cattle with either a cystic or a solid corpus luteum has
shown no deficiency in the progesterone secretion of the luteal glands with cavities.
Echogenicity of the corpus luteum in buffaloes is like that of cows, but it is smaller (10 to
14 mm), more compacter, and the incidence of occurrence of central cavity is less frequent.
Fig. C-34: compact corpus luteum, cow

Fig. C-35: cystic corpus luteum, cow.
Ovarian cysts
Ovarian cysts look like large follicles, but they are larger in size. In the case of a luteinized
follicular cyst, the wall thickness can also assist in its identification. The sectional images of
ovarian cysts are characterized by large anechoic areas. The dark fluid content of thecal follicular
cysts hardly ever contains any reflections. The lumina of luteinized cysts occasionally contain a
network of echoes.
Ovarian cysts have two distinct forms. One form has a thin wall that its structure cannot be
assessed. Most of these structures are likely to be thecal follicular cysts (Fig. C-36). The second
kind is ovarian cysts with a thicker wall. The latter is a few millimeter thick, and usually
hypoechoic. Its echogenicity is similar to that of luteal tissue. These vesicular structures are likely
to fall into the category of luteinized follicular cysts (Fig. C-37). In the mixed or transitional forms
it would, however, be rather more difficult to reliably distinguish between the two types on their
ultrasonic appearance alone. The shape of cysts ranges from round to oval to polygonal,
sometimes even angular. When they occur as single structures on an ovary, they are usually
round. When more than one cyst appears on the same ovary, their shapes are determined by the
relative tensions inside adjacent cysts. Not all follicular cysts that can be seen sonographically on
ovaries of cows can be considered to have a pathological effect. Such cysts have been found
during ultrasound examinations where a distinct corpus luteum of the cycle is present
simultaneously. In such cases the corpus luteum is usually the structure that determines cyclic
events. Ovarian cysts are easy to diagnose. Thecal follicular cysts are recognized by their thin
hyperechoic walls. Luteinized cysts can be diagnosed if they are more than 40 mm in diameter;
their walls are thinner than 5 mm; they persist unchanged for a protracted period of time.
Fig. C-36: Follicle theca cyst, thin walled, buffalo-cow.
Wall of cyst
Fig. C-37: Follicle lutein cyst, thick walled, buffalo-cow.
Ovarian tumors
Ovarian tumors are rare in cattle. Granulosa cell tumor is similar to that of mares. These
often have a strong capsule of connective tissue underneath which lies a labyrinth containing
numerous cystic structures. The contents of the cysts may be serious or hemorrhagic and therefore
generate an anechoic or moderately echoic image on ultrasound examination.
Uterine structures in the cows and buffaloes
Non-pregnant uterus
By a linear ultrasound probe, and when the sound beam is directed dorso-ventrally, a
longitudinal section of the organ is obtained (Fig. C-38). Rotating the probe slightly to the right
and left brings the uterus with its horns into view. Using a linear scanner, between two and four
sections through the uterine horn can often be visualized in a single image (Fig. C-39). The entire
length of the spiraling uterine horn can usually only be depicted in a single image if the uterus is
optimally positioned and the probe is directed at an acute angle to the longitudinal axis of the cow.
During estrus, the thickness of the uterine horns is increases. It decreases during metesrus
until the beginning of diestrus. The uterine horns then become thicker again to reach their widest
diameter during the middle of the cycle, between days 9 and 14. On day 16, a substantial decrease
in the uterine horn diameter occurs. The thickness of the horns increases again until the next
estrus.
Fluid accumulation is visible in the uterine lumen at the time of estrus. They are detected in
about half the heifers on the day of estrus, and in about one third of the heifers during the few
days just prior or after estrus. The most frequent site of the fluid accumulation lies just distal to the
larger curvature of the uterine horn in the part that winds caudolaterally. The size of the fluid
accumulations can vary markedly in non-pregnant uteri. Fluid accumulation measuring 30 to 40
mm in length, and 5 to 10 mm in width, can occur. The fact that fluid can be found in the non-
pregnant uterus is of considerable importance for the sonographic diagnosis of early pregnancy.
Pregnancy can only be diagnosed when embryonic components can be identified with certainty.
During proestrus, estrus, and metestrus a layering of the uterine wall into a hypoechoic
adluminal zone, and a more echoic peripheral zone is recognizable. Laminated uterine walls could
only be seen in a few cows during diestrus but in the majority of cases the uterine wall is
homogeneousely structured. As a result of the edema of its more superficial layers and the
accumulation of secretion, the inner areas of the uterine wall will become less echoic during the
estrogen dominated stages of the estrous cycle. This leads to the layered image of the uterine wall.
This seems to be a similar phenomenon to that observed in estrus mares where the edematous
endometrium is distinct from the more dense tissue of the myometrium.
Fig. C-38: Uterine horn, longitudinal section, cow.

Fig. C-39: uterine horn, cross-sectional view, cow.
Pregnant uterus
Until day 25 of pregnancy, the cross sectional diameter of the allantochorionic and amniotic
vesicle is still so small that a fluid embryonic vesicle can be detected by using higher frequency
ultrasonography of 5 MHz or more. From around day 25 the amount of fluid in the
allantochorionic vesicle increases rapidly so that the embryonic vesicle’s transverse diameter also
becomes considerably greater.
The fluid will lie in the horn ipsilateral to the corpus luteum. Between days 21 and 25 of
gestation the amount of fluid inside the embryonic vesicle has usually increased to such an extent
that it becomes easier to visualize by ultrasonography. The largest fluid accumulation is most
frequently seen for the first time distal to the curvature of the uterine horn (Fig. C-46). This is also
the site where the embryo and its surrounding amnion become detectable for the first time. During
this earliest phase of the sonographic pregnancy diagnosis, particular attention must be paid to
confirm that the observed fluid accumulation is intrauterine. There is always the pitfall of
confusing the blood vessels that run on the surface of the uterus with fluid accumulation within
the uterine lumen.
A positive pregnancy diagnosis can only be made with certainty once an embryo has been
identified. Before day 25 of pregnancy it can often be difficult to find the embryo itself. A thin
hyperechoic and towards the tip of the horn bulging membrane can sometimes be seen inside the
embryonic fluid at days 23 to 26 of pregnancy. Based on its position and the time of its
appearance it is assumed that it represents the allantois.
By day 25 of pregnancy the embryonic vesicle of the bovine reaches a diameter of 10 mm
at the point of its largest expansion. By slight rotations of the ultrasound probe the course of the
embryonic vesicle can be followed into much further areas of the free segment of the pregnant
horn at this stage. It also stretches through the curvature of the horn into the part where the two
uterine horns are fused to form the uterine body. Until day 30 the diameter of the embryonic
vesicle increases from 18 to 20 mm and is then also visible in the contralateral horn. In the
contralateral horn, it is much narrow with a diameter of 4 to 8 mm.
Urinary
E bladder
Fig. C-46: Pregnancy 27d, fluid accumulation at uterine apex (arrow), early appearance of the embryo (E), cow.
The fluid sac of the embryonic vesicle is interrupted in places by folds of the uterus which
projects into the lumen. This creates a pseudo-ampullar image. Typically, 2 to 3 anechoic sections
through the chorionic vesicle are visible on a single ultrasound image at day 25 of gestation. More
sections through the embryonic vesicle will become visible during the next few days so that 4 to 6
sections can often be seen by day 30 (Fig. C-47).
High resolution ultrasound will ensure that the embryo can be detected in all cases of
bovine pregnancy between days 25 and 30. The embryo’s echogenicity is a little more intense
than that of the neighboring endometrium. Since the embryo lies very close to the uterine wall for
the first month of pregnancy, it may prove difficult to find. It projects from the wall into the
anechoic uterine lumen and can be identified by the presence of a heartbeat. The embryo starts to
move away from the wall during the next few days and by day 30, it is completely surrounded by
fluid.
On the average, the length of the embryo increases from 5 to 12 mm in the period from day
25 to day 30 of pregnancy. If it is clearly visible, its heart beat should be detectable. The heart is
the first organ of the bovine embryo that can be identified by ultrasonography.
Urinary bladder
Fig. C-47: Three cross sections through the amniotic vesicle, 42d pregnancy, cow.
By using 5 MHz ultrasound it should be possible to demonstrate the embryonic vesicle with
a relative ease by day 25. Under certain conditions the detection of an allantoic membrane a few
days prior to the detection of the embryo is possible. With a frequency of 3.5 MHz, the
demonstration of the embryo is usually delayed by about 5 days. The crown-rum length (CRL) of
the embryo reaches 12 mm around day 30, 15 mm by day 35, and 20 mm by day 40. Occasionally
around day 30, but usually around day 35, the amniotic vesicle becomes apparent (Fig. C-48). A
few millimeters away from the embryo it forms a very thin, arched, hyperechoic line which
surrounds the embryo. Around day 40 the mean diameter of the amniotic vesicle is about 2.5 cm
and the CRL about 2 cm. The placentomes also become visible for the first time between days 30
and 40 (Fig. C-49). On average, the first appearance of knob like protrusions can be expected
around day 35. Between days 20 and 50, the embryo grows at a rate of 1 mm per day. By day 50,
it would thus have a CRL of about 35 mm. The cross sectional diameter of the placental vesicle
also increases appreciably between days 30 and 70 of pregnancy. It reaches 25 mm by day 40, 40
mm by day 50, and 60 mm by day 70, then it increases rapidly as pregnancy advances (Fig. C-
50).
The outline of the fetus with its head, extremities, and umbilical cord become visible after
day 40 of pregnancy. At this time first ossification centers can be noticed in the vertebrae, the ribs
and the pelvic bones, on the upper and lower jaws, on the femur and humerus, as well as on the
radius, ulna, and tibia (Fig. C-51).
The pseudo-ampullary appearance of the pregnant uterus is particularly pronounced during
the 2nd month of pregnancy. At this time numerous well developed uterine folds bulge into the
lumen, and divide the early pregnant uterus into compartments. As pregnancy continues, these
circular folds of the uterine wall gradually retract so that by day 70 the compartmentalization
becomes less prominent.
Embryo
Fig. C-48: Amniotic vesicle (arrow), 38d, cow.
Fig. C-49: Placentomes, 60d, cow.
Fig. C-50: Placentome, 150d pregnancy, cow.

hl fl
t ab h
Fig. C-51: Organization of the fetus into head (h), fore limbs (fl), abdomen (ab), hind limbs (hl), and tail (t), 52d pregnancy, cow.
The low frequency ultrasound with its deeper scanning depth, has important advantages
during the more advanced stages of pregnancy. When a 5 MHz probe is used the CRL of a fetus
may not be measurable after day 60. Around this time the CRL reaches 6 cm which is the
maximum scanning width of most 5 MHz linear probes. If a lower frequency is selected the fetus
may still be scanned until day 90.
In advanced pregnancy parts from the fetus, the placentomes as well as the membranes of
the amnion and allantois and their fluids can be demonstrated. The placentomes bulge into the
uterine lumen in their characteristics appearance. During the third trimester of pregnancy they are
frequently demonstrated with a very hyperechoic border. Their inner echoes are of moderate
intensity. A tree like, more echoic inner structure, can occasionally be seen in their centers (Fig.
C-51).
The amniotic fluid remains anechoic during the first trimester of pregnancy, it may contain
increasingly more reflections from the second trimester onwards. They are caused by the
increased cellular contents and viscosity of the amniotic fluid. As the pregnancy progresses, these
reflections may assume a snow-storm-like appearance (Fig. C-52, C-53). The allantoic fluid
remains anechoic for many months. Only during the sixth month of pregnancy a few echoes start
to appear in it, which then increase rapidly in density (Fig. C-53).
The fetuses cannot be reached by transrectal sonography during the last trimester of
pregnancy. During this time diagnostic conclusions can be drawn by imaging the uterus filled
with placental fluid, the placentomes, or the amnion and allantois.
allant
amnio
fetus
Fig. C-52: Amniotic and allantoic fluids (clear), 3 m pregnancy, cow
Fig. C-53: Amniotic (snow-like appearance) and allantoic (clear) fluids, 7.5 m pregnancy, cow.
The achievement and visualization of individual organs depend on the stage of the
pregnancy, the intra-uterine position of the fetus, and its mobility. Individual organs or body parts
can also be identified when they have reached the minimal resolution capability of the scanner
used, and if they have a characteristic sonographic appearance that allows them to be
distinguished. The earliest time at which certain organs become visible is closely connected with
the typical events of organogenesis.
The deep viewing field of the sector scanner is wider than that of the linear scanner.
Therefore, sector scanners may be better used for the sonographic examination of the fetus in
advanced pregnancy.
Organization of the embryo into head, body, and extremities can be recognized between
days 35 and 40 of pregnancy. The eye can be recognized on about day 40 of pregnancy. From day
70 of pregnancy, echoic structures become visible within the eye; they originate from the anterior
and posterior walls of the lens (Fig. C-54).
Eye-lens
eye
Fig. C-54: Fetal eye and eye-lens, 7.5 m pregnancy, cow
Vertebrae
Ribs
Fig. C-55: Fetal ribs and vertebrae, 75d pregnancy, cow.
Ossification develops firstly in the skull bones about the end of the second month of
pregnancy. The first large hyperechoic structure is found in the region of the mouth; it is found at
the site of the mandible. At the end of month 3 of pregnancy the ossification processes have
progressed so far that individual skull bones can be recognized by their typical shapes (Fig. C-55).
A transverse section through the cranium shows a round cranial cavity. A sagittal section through
the cranium results in the depiction of an oval cranial cavity the longest diameter of which lies in
the frontooccipital direction. The cranial cavity can be seen until the 7th moth (Fig. C-56, C-57).
During the last two months of pregnancy the bones in the roof of the skull absorb so much
ultrasound waves that the energy reflected from the bones at the base of the cranium is not
sufficient for the production of an image on the monitor. The inner cavity of the cranium is clearly
less echoic than its surrounding cranial bones. At relatively early stage, it contains reflections of
varying intensities which originate from different parts of the brain. A frontal section through the
cranium reveals a strip like straight echo, which runs centrally from cranial to caudal. These
reflections caused by the falx cerebri which lies in between the two hemisphere of the brain and
divides the cranium into two symmetrical halves. Two round echoes lie on either side of the
central line. These echoes originate from the lateral ventricles and their chorioid plexus. They
contrast against the remaining hypoechoic parts of the brain cortex. As the pregnancy progresses,
the brain substance develops faster than the ventricles, resulting in a relative decrease of the
echogenicity inside the cranial cavity. The hyperechoic structures in the vicinity of the brain
originate from the meninges with the chorioid plexus and the lateral ventricles, whereas the brain
tissue themselves are less echoic.
Fig. C-56: Fetal head, ossification centers (echoic areas with distal shadows - arrows), 2.5m pregnancy, cow.
Skull
Brain hemispheres
Fig. C-57: Fetal cranial cavity, 103d pregnancy, cow.

The spine can be seen as early as week 5 of pregnancy. At this time a thin line which, due to
its higher echogenicity, stands out against the surrounding tissues and becomes evident in the
back region of the embryo. At about week 8 of pregnancy the development of vertebral
ossification centers has apparently progressed far enough so that small, hyperechoic foci can be
detected. Ossification of the vertebrae commences in the vertebral body and then extends in the
vertebral arches. The narrow, hypoechoic band of the spinal canal is delineated by a string of
hyperechoic discs of two sides. This double row of bright echoes can only be seen on slightly
paramedian sections of the fetus. As the ossification of the vertebrae progresses, the typical image
of shadowing becomes evident in their background (Fig. C-58). From below the vertebrae
hypoechoic, shadows stretch into the depth of the image. The width of each shadow is
approximately the same as that of the bony structure in the foreground. The shadowing effect is
caused by the absorption of sound waves by the bony tissue which then causes very little sound to
reach the tissues, immediately behind the bone. The spinal cord is best depicted on an exact
median section. This approach allows the sound waves to pass between the ossification centers of
the vertebral arches on either side without generating any reflection.
Shadows
Heart
Fig. C-58: Fetal vertebrae shadows (hyperechoic), 103d pregnancy, cow.
The ribs can be distinguished at the same time as the vertebrae. The ribs, thoracic vertebrae
and sternum are all characterized by hyperreflective images. On horizontal sections the rows of
ribs cross sections of both halves of the thorax form a cone. Shadow artifacts behind the spinal
column can be observed in the background of the ribs, and the thoracic vertebrae. In advanced
pregnancy the increased absorption of sound waves by the bones restrict the examination of
organs lying behind the ribs. The sternum does not produce a single row of disc (Fig. C-58).
The cranial part of the thoracic cavity is filled by the heart (Fig. C-58). The heart is very
striking with its obvious pulsation, its hypoechoic heart chambers which are surrounded by echoic
myocardial walls and subdivided by the bright septa and valves. The space between the heart and
the diaphragm is filled with the echo of the lung. The lung echo is coarsely granular, very similar
to that of the liver. The diaphragm itself cannot be illustrated sonographically. Its position can,
however, be determined by subtle differences in the echogenicity between liver and lung.
The stomach and the liver can be seen in the background of the last few ribs. The liver can
be recognized by its coarsely granular echo, which is traversed by several large vessels in the
center (Fig. C-59).
liver
Fig. C-59: Fetal liver, 4 months pregnancy, cow.
The stomach lies between the liver and the contralateral ribs. The stomach becomes
ultrasonically visible shortly later than the heart at about day 40 of pregnancy. It constitutes the
largest anechoic area in the abdomen of the fetus, and it produces the typical image of a fluid
hollow organ (Fig. C-60, C-61). As pregnancy progresses, the echogenicity of the stomach
contents increases. At about month 5 of pregnancy there will be already obvious echogenicity in
the stomach. Sometimes they will even develop into snow storm like reflections.
rumen
omasum
Fig. C-60: Fetal stomach, rumen and omasum, 103d pregnancy, cow.
omasum
Fig. C-61: Fetal stomach (omasum), 5m pregnancy, cow.
The abdominal aorta is seen in a median section through the fetus as a hypoechoic band
running just underneath the many bright echoes of the spinal column (Fig. C-62).
The kidney can be observed in a horizontal section between the iliac bone and the last rib.
In a transverse section with the beam directed dorsoventrally they can be found at the level of the
lumber vertebrae, immediately ventral and lateral to the spine. They are relatively hypoechoic,
and they present their typical anatomical structure, including multiple papilla divided by deep
fissures. In longitudinal section, a more hyperechoic outer cortical and a less echoic central
meduallary region can be recognized (Fig. C-63).
The urinary bladder is shown with its anechoic, fluid filled lumen and lies in the midline of
the ventral abdomen, just at the pelvic inlet (Fig. C-64). On either side of the bladder the umbilical
arteries, which run in the direction of the umbilicus, can be found. The degree of filling of the
bladder appears to vary.
The pelvic area can be observed by the end of the second month of pregnancy when its
ossification centers become visible. Ossification in larger long bones, such as humerus, radius,
ulna, and metacarpus can be identified for the first time around weeks 10 to 12 of pregnancy (Fig.
C-64). Femur, tibia and metatarsus can only be identified reliably starting week 10 of pregnancy
(Fig. C-65).
Aorta
Rumen
Fig. C-62: Fetal aorta, 5m pregnancy, cow.
Rumen
Kidney
Fig. C-63: Fetal Kidney, 5m pregnancy, cow.

UB Tibia
Fig. C-64: Fetal pelvis, urinary bladder (UB) and tibia, 3m pregnancy, cow.
forelimb
Fig. C-65: Fetal forelimb, 2m pregnancy, cow.
Fetal sex determination

Effect of gestational age on the possibility and accuracy of the transrectal ultrasonographic
fetal gender determination has been studied. Each cow was examined 18 times, with a total
number of 270 examinations for all animals. In 55.6% of the cases (150/270), the genitalia
(genital tubercle, scrotum or mammary gland) could be observed. The ability to observe the
genitalia increased from 26.7% at day 49 to 100% at day 56 of gestation (p < 0.05). Between days
56 and 98, the ability to see the genitalia was 100%. Thereafter, the ability significantly decreased
with advancing of gestational age, (p < 0.05). It was impossible to find the genitalia by days 161
and 168 of gestation. Fetal gender determination between days 49 and 63 depended on the
location of the genital tubercle. For its visualization, the fetus must be located in a frontal position
(Fig. C-66). In this stage both cross-sectional and sagittal views were not valid for fetal gender
determination. By day 49, determination of fetal gender was possible in four of 15 animals, two
males and two females. In male fetuses, the genital tubercle was a hyperechogenic, bilobar
structure, located cranial to the hind limbs (Fig. C-67). Contrarily, in female fetuses, the genital
tubercle was located just behind the hind limbs (Fig. C-68). By day 70, the frontal, cross-sectional
and sagittal views of the fetus could be used equally for fetal gender determination. However, by
progress of gestation the usefulness of frontal view for fetal gender determination decreased from
eight of 15 cases at day 70 to none of 15 cases by day 98, while that of cross-sectional view
increased from five of 15 cases at day 70 to 11 of 15 cases at day 98. In occasional cases, sagittal
view was a diagnostic one, being two of 15 cases at day 70 and four of 15 cases at day 98. In the
cross-sectional view, the genital tubercle appeared in male fetuses as a round hyperechogenic
structure at the connection of umbilical cord with the fetal body (Fig. C-69), while it was absent in
this area in females (Fig. C-70). The fetal scrotum could be observed between the two hind limbs
by day 70 in eight of 15 cases and in all male fetuses by day 77 (Fig. C-71). In parallel, the fetal
mammary gland was firstly visualized between the hind limbs by day 70 in five of 15 cases and in
all female fetuses by day 77 (Fig. C-72). The fetal gender was correctly determined in 146 of the
150 possibly diagnosed occasions (overall accuracy 97.3%), as there was agreement between
results of examination by transrectal ultrasound and results of direct observation of calves at birth.
Gender was wrongly determined in 4 of the 150 possibly diagnosed cases: two at day 56, one at
day 63, and one at day 70 of gestation. In the all four wrong cases, a male fetus was incorrectly
diagnosed as a female one, either due to poor resolution of the view or because the miss-
observation of the genital tubercle. The accuracy of correctly identifying fetal gender did not
change significantly with gestational age.
gt
Fig. C-66: Genital tubercle (gt) between two hind limbs, indifferent stage, 49d pregnancy, cow.
gt
Fig. C-67: Genital tubercle (gt) moved cranially toward umbilical cord, male fetus, 55 d pregnancy.
Fig. C-68: Genital tubercle (gt) moved caudally toward the origin of the tail, female fetus, 57d pregnancy, cow.
Fig. C-69: Genital tubercle (gt) at connection of umbilical cord (uc) with the body of the fetus, male fetus, 88 pregnancy, cow.
Fig. C-70: No genital tubercle at connection of umbilical cord with the body, female fetus, 67d pregnancy, cow.
scrotum
Fig. C-71: Scrotum between two hind limbs, male fetus, 90d pregnancy, cow.
Mammary gland
Fig. C-72: Mammary gland and teats between two hind limbs, 92d pregnancy, cow.
In buffaloes, the embryo and AV were detected in all buffalo-cows by the 4th and 5th week
of pregnancy, respectively (Fig. C-73). Organization of the embryo into head, body, and limb
buds was firstly observed in some animals (4/12) by the 6th week and in all animals by the 7th
week (Fig. C-74). Beginning of the ossification was observed in the head, ribs and vertebrae in
most animals (8/12) by the 8th week and in all animals by the 10th week (Fig. C-75). The
placentomes were firstly observed by the 10th week as small hyperechogenic nodules (Fig. C-76).
The omasum was first detected as circumscribed hyperechogenic structure by the 10th week (Fig.
C-77). The amniotic fluid remained clear until the 14th week of pregnancy, when it becomes
slightly turbid. Definite turbidity is observed by the 30th week. The allantoic fluid remains clear
during the whole observation period (Fig. C-78). The feta parts and organs develop differently,
with decreasing (CRL, BPD, ABD, OMD and THD) or increasing (AVD, UTD, RUL, EBD, and
PLD) growth rate by progress of the gestation (Figs. C-79, C-80, C-81) . All regression and
correlation between gestational age and each of the studied parameters are highly significant
(P<0.0001). Gestational age affects significantly (P<0.05) the possibility of the ultrasonic fetal sex
determination (Table C-1). Fetal sexing is unreliable before the 8th week gestation. The
possibility increases through the 10th week, remains constant between the 10th and 14th weeks,
and decreases gradually until the 24 week pregnancy. After this time, fetal sexing is impossible
due to the far position of the fetus. The fetal gender is correctly assigned in 68 of the 70 possibly
diagnosed occasions (overall accuracy 97.1%), as there is agreement between results of
examination by transrectal ultrasound and confirming results of direct observation of calves at
birth. In male fetuses, the genital tubercle (phallus) is a hyperechogenic, oval or sometimes round
structure, located cranial to the hind limbs and at the abdominal attachment of the umbilical cord.
In female fetuses, the genital tubercle (clitoris) is located behind the hind limbs and toward the
base of tail. The fetal scrotum could be observed between the two hind limbs firstly by the 10th
week of gestation. The fetal udder/teats are firstly viewed between the hind limbs, also by the 10
week. The testes were not observed in the scrotum during the observation period. Early in
gestation (8th week) fetal sexing depends only on the view of the fetus in the frontal plane. The
importance of this view decreases with the progress of the pregnancy (P<0.05). Contrarily, the
importance of the sagittal view increases with the advancement of gestation (P<0.05). The cross-
sectional plane could be used from the 10th to 18th weeks of gestation (Fig. C-82). The buffalo-
fetuses change their presentation frequently until the 28th week of pregnancy. From the 30th week
onwards, all the fetuses in the present material turn into the anterior presentation (Fig. 83).
Fig. C-73: Buffalo fetus 4 weeks pregnancy. Fig. C-74: Buffalo fetus 50 d pregnancy.
Fig. C-75: Head of buffalo fetus, 8 weeks. Fig. C-76: Placentomes, 10 weeks pregnancy.
Allantoic fluid
Amniotic fluid
Fig. C-77: Buffalo fetus, omasum, 10 weeks pregnancy. Fig. : Fetal fluids of buffalo fetus, 30 weeks pregnancy.
Fig C-79: Growth rate of fetal parts of the buffalo fetus: crown rump length (CRL), amniotic vesicle (AVD), uterine diameter
(UTD), biparital diameter (BPD).
Fig C-80: Growth rate of fetal parts of the buffalo fetus: abdominal diameter (ABD), chest diameter (chest diameter),
ruminal length (RUL), omasal diameter (OMD).
Fig C-81: Growth rate of fetal parts of the buffalo fetus: eye-ball diameter (EBD), placentome diameter (PLD).
Table C-1: Possibility, accuracy and criteria used for ultrasonographic fetal sex determination in buffaloes (n=12)
Gestational Possibility Accuracy Criteria
age (week) [n (%)] [n (%)] GT in FV GT in CSV Scr/udder in SV
[n (%)] [n (%)] [n (%)]
8 5/12 (41.7) 4/5 (80) 6/6 (100) 0/6 (0.0) 0/6 (0.0)
10 12/12 (100) 12/12 (100) 2/12 (16.7) 5/12 (41.7) 5/12 (41.7)
12 12/12 (100) 11/12 (91.7) 2/12 (16.7) 1/12 (8) 9/12 (75)
14 12/12 (100) 12/12 (100) 0/12 (0.0) 4/12 (33.3) 8/12 (66.7)
16 11/12 (91.7) 11/11 (100) 0/12 (0.0) 4/11 (36.4) 7/11 (63.6)
18 10/12 (83.3) 10/10 (100) 0/10 (0.0) 2/10 (20) 8/10 (80)
20 6/12 (50) 6/6 (100) 0/6 (0.0) 0/6 (0.0) 6/6 (100)
22 2/12 (16.7) 2/2 (100) 0/2 (0.0) 0/2 (0.0) 2/2 (100)
24 0/12 (0.0) - - -
overall 70/108 (64.8) 68/70 (97.1)
GT: genital tubercle; FV: frontal view; CSV: cross-sectional view; SV: sagittal view; Scr: scrotum.
Fig C-82: Fetal sex determination in buffalo fetus according to location of the genital tubercle in frontal view (gt, a:
undifferentiated; b: male fetus; c: female fetus); presence of the scrotum (d) or udder (e) in sagittal view; or presence or
absence of the genital tubercle in cross-sectional view (f).
Fig. C-82: Changes in fetal presentation during gestation.

Uterine pathology
Postcoital pyometra
A 4 year cross-bred cow was submitted in the clinic for pregnancy diagnosis three months
after mating. Rectal palpation revealed a large sized uterus comparable to the mating date,
however, the uterine wall was thick. Fetal membrane slip, placentomes and fetal balottment were
absent. Sonographically, the uterus was greatly dilated, folded, and filled with an echogenic thick
content (Fig. C-40). The echogencity of uterine content was higher than that of the uterus. This
case was injected with Prostaglandin F2 (0.750 mg tiaprost , i.m.). One day after the injection,
a copious amount of purulant vaginal discharge started to escape. The purulant vaginal discharge
continued for 3 successive days. On the last day, the animal showed clear vaginal discharge. Post-
treatment sonographic examination revealed a smaller uterus which resembled that of the non-
pregnant animals. This cow was conceived after the elapse of two successive cycles.
Pus
Uterine folds
Fig. C-40: Post-coital pyometra in a cow: Longitudinal section in the uterine horn revealed collection of echogenic purulent exudates
within the uterus. The uterus greatly dilated and folded on the accumulated pus.
Postpartum pyometra
In such a case, the uterus is dilated with thick echogenic content (Fig. C-41). The cervix and
vagina are filled with hypoechogenic fluid tinged with some hyperechogenic flaky reflection of
particles (Fig. C-43).
Such a cow should be treated with systematic antibiotic and local irrigation of the uterus
with lotagen solution 4%. A single dose of Prostaglandin F2 (0.750 mg tiaprost ) injected
intramuscularly would be a significant improvement for the case.
Pus
Fig. C-41: Post-partum pyometra in a cow: Sagital-section in uterine horn showing accumulation of an intensive echogenic purulant
material.
Fig. C-42: Cervicitis in a cow: Collection of hypoechogenic fluid (arrow) between cervical rings.
Hydrometra
A seven year native-bred cow submitted to the clinic with a history of abnormal pregnancy.
The cow was mated five months ago. Attached examination report from the regional veterinary
service suspected that the case is a mummified fetus, as a tentative diagnosis according to the
rectal findings. Rectal examination revealed hard irregular masses of different sizes, from the size
of an egg to big potato, were palpated in the pelvic and caudal part of abdominal cavities. The
uterus was difficult to palpate. Ultrasonic rectal examination revealed many irregular and
sometimes elliptical gray masses in the pelvic and the caudal abdominal cavities. Such masses
were found clearly outside the uterus. The uterus was located in the caudal part of the abdominal
cavity, filled with clear hypoecogenic fluid (dark), without placentomes or fetal membranes or
fetus (Fig. C-43). The animal was discarded from breeding.
Fetal death
A Friesian heifer was submitted to the clinic to test the viability of her fetus. The heifer was
inseminated 8 months ago; however, the abdominal circumference and the udder were not
enlarged as expected. Transrectally, the uterus was partially in the pelvic cavity comparable to 3
months of pregnancy. The right horn was the larger one, and was not freely movable, but adhered
to the surrounding tissues. Sonographic examination showed a bony structure of an inert fetus in
the ventral part of the gravid horn (Fig. C-44). This fetus did not show any internal organs. Less
echogenic areas, as displayed by the fetal fluids suspending the fetus. Estimating the CRL
indicating that this fetus died at the age of 75 days. The heifer was discarded from breeding.
Fig. C-43: Hydrometra in a cow: the uterus dilated with a clear hypoechogenic fluid. There was no placentmoes, fetal membranes or
fetus. The uterus extended to the abdominal cavity. Many solid, irregular echogenic objects were detected in abdominal cavity
.
Fig. C-44: Fetal death in a heifer: Only skull and ribs (arrows) of the fetus could be observed. The internal organs were completely
absent. The fetal fluid changed to give a snow-storm effect.
Hydrallantois
An 8 month balady heifer was submitted to the clinic with heavy enlarged abdomen. Rectal
examination was very difficult, as the uterus was filled with very large amount of allantoic fluid.
Ultrasonography showed large amount of hypoechoic fluid in the uterus, the fetal membrane
floated in the fluid, and the fetus was difficult to reach (Fig. C-45). Allantocentesis was carried
out in the left lower flank region for 24 h, followed by cesarean section in the upper left flank.
Large amount of allantoic fluid was escaped. The fetus was about 5 months old, edematous, but
not putrefied. The heifer passed the operation without large complication and submitted to the
clinic 14 days later only for wound infection.
Fig. C-45: Hydrallatoid, heavy accumulation of allantoic fluid in pregnant uterus, cow.
Ultrasonography of the reproductive tract of the Ewe and Doe
The ultrasound examination of the genital tracts of
small ruminants can be performed either through the trans-
cutaneous ultrasonography by applying the ultrasound probe
to the ventro-lateral side of the abdomen, or through the
trans-rectal approach, by placing the probe into the rectum.
The transrectal examination is more accurate than the
transcutaneous method until day 35 of pregnancy. Between
days 35 and 70 both methods appear to be equally accurate.
The transcutaneous approach is preferred during the second
half of pregnancy. Generally, scanners with sector, linear
and convex probes at frequencies 3.5 to 7.5 can be used for
both approaches. Linear probes appear better suited for the
transrectal examinations, whereas sector probes are
preferred for transcutaneous examinations.
To perform a transcutaneous sonography, the probe
with sufficient amount of ultrasound gel is placed to the groin
area immediately cranio- lateral of the udder (Fig. C-83). In
the majority of sheep breeds (but not in goat) this area is
relatively free of wool and hair, allowing for good coupling of the probe without prior clipping of
the hair in the area. During the last trimester the pregnant uterus extends so far forward that the
probe has to be moved cranially in order to permit a complete examination of the fetuses. The
transcutaneous ultrasonography can be performed while the ewe is standing, sitting or in a laying
position. The examination should start on the right hand side of the animal. In most cases the full
rumen pushes the pregnant uterus to the right side. The probe is applied to the hairless area in
front of the udder, the sound waves are directed dorsally and slightly caudomedially. The probe is
then pressed moderately against the abdomen in the direction of the urinary bladder.
For transrectal ultrasonography, the urinary bladder should be found and depicted. It is
easily recognized by its anechoic lumen and typical shape. The non-pregnant uterus appears in the
area of the apex of the bladder. The non-pregnant uterine horns are usually found cranially and
ventrally, sometimes also laterally, to the urinary bladder. Ultrasound probes attached with
connector may be used for the easy trans-rectal examination. Nowadays, certain probes with long
hands are manufactured especially for trans-rectal examination in small ruminants (Fig. C-84). It
is then pushed cranially for about 15 cm where the urinary bladder should become visible (Fig. C-
85). Once the bladder has been identified, the probe is advanced slowly while it is also swiveled
laterally through 45 degrees in both directions until the uterus comes into view. Occasionally,
feces that lie between the probe and the gut wall may obscure the image; by moving the probe
back and forth a little, or by reintroducing it, this hindrance can be removed. When the sheep in
their second or third trimester of pregnancy are scanned, it may be helpful to elevate their
abdomen a little in order to better visualize parts of the pregnant uterus.
Fig. C-83: Transcutaneous sonography in sheep and goats.

Fig. C-84: Ultrasound probe with long hand for trans-rectal examination in small ruminant.
Fig. C-85: Ultrasonic pictures of different sized genital tracts of ewes.

Examination of the ovaries

Ovarian follicles and corpora lutea of the sheep and goats produce echo patterns similar to
those observed in cattle. The largest follicles of sheep had a diameter of 6-10 mm on the day of
ovulation (Fig. C-86), and the diameter of corpus luteum rangs from 9 to 15 mm in diameter (Fig.
C-87).
Fig. C-86: Follicle, 6 mm in diameter, ewe.
Fig. C-87: Corpus luteum, 11 mm in diameter, ewe.
Follicular dynamic and luteal development in sheep

In a study carried out by the author and his co-workers on ewe lambs in subtropics, all the
lambs were cycling in all studied seasons. Complete ovarian follicular data were obtained for 20
interovulatory periods (IOP) during spring (n=7), autumn (n=7), and winter (n=6). Three (13/20,
65%) and two (7/20, 35%) follicular waves were detected per IOP (Fig. C-88). None of the
characteristics of the largest follicle of the first (LF1), second (LF2) or third (LF3) follicular
waves were affected by the season (Table C-2). The number of waves per cycle affects certain
patterns of follicular characteristics (Table C-3).
The numbers of small, medium and large follicles were aligned with the beginning and end
of an average length of 17 d for the cycle with 3 waves and 14 d for cycle with 2 waves. The
mean daily number of all follicles 2 mm in diameter was significantly (P = 0.008) higher in
winter (5.29  0.2) than in spring (4.27  0.2) or in autumn (4.57  0.2). In cycles with 3 waves, a
significant (P = 0.01) day effect was observed for the mean daily number of small follicles. A
numerical, but not significant, increase was seen for the mean number of the medium-sized
follicles. The mean daily number of large follicles varied significantly among days of the IOP (P
= 0.0001). Similar fluctuations of the mean follicular number were seen in cycles with two waves
(Fig. C-88). However, these fluctuations did not approach the significance level for the small and
medium follicles, but were significant for the large ones (P = 0.01).
The effect of season on luteal function is shown in (Table C-4). The CL developed slowly
(P = 0.04), achieved maximum diameter later (P = 0.02), and started to regress later (P = 0.05) in
autumn. Regression rate of the CL was significantly slower in winter (P = 0.006). It appeared (P =
0.03) and regressed (P = 0.01) significantly earlier in animals with two waves per cycle than in
those with three waves. Double ovulation was observed in three ewe lambs (15%), all in autumn.
Corpora lutea with central cavities were detected in seven of the twenty one CL (33.3%). These
cavities were firstly observed on D 3.4  1.5 (range D 1-4), their diameters ranged between 5.0
and 7.5 mm at first detection (average 5.9  0.6 mm), which gradually decreased as the cycle
advanced, to disappear completely on mean D 9.0  1.5 (range D 5-12).
A total of 32 single ovulations were observed during the twenty IOP of the seven lambs.
Ovulations were distributed equally (16:16) between the right and left ovaries. The number of the
largest follicles located in the left (n = 25) versus the right ovary (n = 29) did not differ
significantly among wave categories. The frequency in which the largest follicles were in the
same (15/46, 32.6%) versus the opposite (31/46, 67.4%) ovary to the CL did not differ
significantly (P = 0.09). The largest follicles were located in the same (n = 18) or opposite ovary
(n = 13) to the previously largest follicle in almost equal frequencies.
Table C-2: Effect of season on follicular characteristics throughout an entire IOP in Ossimi ewe lambs
Season Total
Characteristics Spring Autumn Winter
n=7 n=7 n=6 n=20
IOP 17.0  0.7a 17.0  0.9a 15.5  1.0a 16.55  0.5
Waves/IOP (2) 2 2 3 7
(3) 5 5 3 13
LF1
Emergence (day) - 0.3  0.4a 0.0  0.5a 0.0  0.3a - 0.1  0.2
GR (mm d-1) 1.21  0.2 a
1.05  0.2 a
1.28  0.2a 1.18  0.1
MD (mm) 6.21  0.4a 5.9  0.3a 6.33  0.2a 6.14  0.2
DMD 3.71  0.2a 4.43  0.7a 3.67  0.6a 3.89  0.3
DA 5.57  0.6a 6.57  0.7a 5.67  0.7a 5.95  0.4
-1
AR (mm d ) 0.92  0.1a 1.08  0.1a 0.77  0.1a 0.93  0.1
LF2
Emergence (day) 5.86  0.6a 5.57  0.4a 6.67  0.7a 6.0  0.4
GR (mm d-1) 0.79  0.1 a
0.84  0.1 a
1.07  0.1a 0.89  0.1
MD (mm) 6.07  0.3a 6.21  0.5a 7.18  0.4a 6.46  0.3
DMD 10.71  0.8 a
10.57  0.9 a
11.3  0.6a 10.85  0.5
DA 11.0  0.8a 11.8  0.9a 12.3  0.2a 11.62  0.4
AR (mm d-1) 0.93  0.01a 0.6  0.04a 1.3  0.2a 1.08  0.08
LF3
Emergence (day) 11.4  0.2a 11.6  0.5a 12.3  0.6a 11.7  0.3
GR (mm d-1) 0.88  0.1 a
0.89  0.04 a
0.93  0.1a 0.9  0.1
MD (mm) 6.3  0.3a 5.08  1.0a 5.83  0.1a 5.7  0.4
DMD 16.8  0.2a 16.2  0.8a 15.7  0.8a 16.3  0.3
IOP: interovulatory period; LF1, LF2 and LF3: largest follicle of the first, second and third follicular waves; GR: growth rate; MD:
maximum diameter; DMD: day of maximum diameter; DA: day of atresia; Values with different superscript letter in the same row differ
significantly. Data in mean  SEM.
Table C-3: Effect of number of waves per IOP on follicular characteristics of Ossimi ewe lambs
Characteristics Number of waves/IOP
Two waves Three waves
n=7 n=13
IOP 14.3  0.6a 17.77  0.4b
LF1
Emergence (day) 0.29  0.3a - 0.31  0.3a
GR (mm d-1) 1.26  0.2a
1.14  0.1a
MD (mm) 6.36  0.2a 6.02  0.3a
DMD 4.71  0.8a 3.54  0.3a
DA 6.71  0.8a 5.54  0.5a
AR (mm d-1) 0.79  0.1a 1.0  0.1a
LF2
Emergence (day) 7.29  0.7a 5.31  0.3b
GR (mm d-1) 1.05  0.2a
0.8  0.1a
MD (mm) 7.36  0.4a 5.97  0.2b
DMD 12.71  0.8a 9.85  0.3b
DA - 11.62  0.4
AR (mm d-1) - 1.08  0.1
LF3
Emergence (day) - 11.69  0.3
GR (mm d-1) - 0.9  0.01
MD (mm) - 5.72  0.5
DMD - 16.31  0.4
IOP: interovulatory period; LF1, LF2 and LF3: largest follicle of the first, second and third follicular waves; GR: growth rate; MD:
maximum diameter; DMD: day of maximum diameter; DA: day of atresia; Values with different superscript letter in the same row differed
significantly. Data in mean  SEM.
Table C-4: Effect of season on luteal function throughout an entire IOP in Ossimi ewe lambs
Season Total
Characteristics
Spring Autumn Winter
n=7 n=7 n=6 n=20
GR (mm d-1) 1.43  0.2a 0.69  0.2b 1.04  0.4ab 1.05  0.2
MD (mm) 12.7  0.4a 13.82  0.6a 13.7  0.5a 13.39  0.3
DMD 5.43  0.6a 8.57  0.5b 6.0  1.0a 6.7  0.5
DR 11.57  1.2a 14.57  0.9b 12.2  0.5a 12.8  0.6
RR (mm d-1) 1.78  0.3a 1.91  0.3a 0.92  0.1b 1.57  0.2
Double CL (n) 0/7a 3/7a 0/6a 3/20
Cystic CL (n) 1/7a 4/10a 2/6a 7/23
P4 (ng mL–1)
D0 0.7  0.1a 0.83  0.1a 0.6  0.1a 0.73  0.1
D4 2.96  0.5a 3.03  0.6a 1.8  0.6a 2.62  0.4
D7 4.0  0.4a 5.92  1.4a 3.74  0.3a 4.64  0.6
D 11 3.72  1.0a 6.0  0.8b 3.4  0.8a 4.37  0.6
D 14 1.03  0.2a 3.87  0.9b 2.7  0.7b 2.68  0.5
D0 0.5  0.1a 0.8  0.2a 0.7  0.1a 0.73  0.1
CL: corpus luteum; GR: growth rate; MD: maximum diameter; DMD: day of maximum diameter; DR: day of regression; D 0: day of
ovulation. Values with different superscript letter in the same row differ significantly (P <0.05). Data in mean  SEM.
9
8
7
6 LF1-3w
Diameter mm
5 LF1-2w
LF2-3w
4
LF2-2w
3 LF3-3w
2
1
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Days of estrous cycle
Fig. C-88: Turnover of the large follicles in cycles with 3 or 2 follicular waves. LF1-3w, LF2-3w, LF3-3w: the large follicles of the first, second
and third waves in cycles with 3 waves, respectively. LF1-2w, LF2-2w: the large follicles of the first and second waves in cycles with
2 waves. 0: day of ovulation. Values in means  SEM.
Examination of non-pregnant uterus

The non-pregnant uterus is usually located in the pelvis in the vicinity of the apex of the
urinary bladder. During transrectal examination, a sagittal section through the uterus is produced
if the probe is held dorsally above the uterus and its scanning plane is directed ventrally and
parallel to the longitudinal axis of the body (Fig. C-89). On cross-section, the uterine wall
produces a homogenous coarsely granular echo (Fig. C-90).
The days of estrous cycle have a significant effect on the mean number of the uterine cross
sections. The lowest numbers are recorded around the day of ovulation. Also, a significant day
effect is observed for the mean diameter of the uterine cross sections. Maximum mean uterine
diameters are recorded around the day of ovulation, and on D 4-5. Negative correlation is found
between the number of uterine cross sections and their diameters. Mean scores representing the
amount of fluid in the uterine horns are depicted. There is a significant effect of the days of
estrous cycle on the amount of uterine fluid. Intrauterine fluid accumulation is ultrasonically
visible as mobile, free, and nonechogenic (fluid-filled) areas with poorly defined borders within
the uterine lumen (Fig. C-91). Large amount of uterine fluid are recorded around the time of
ovulation in 6/18 (33.3%) of the IOP. This fluid appears 2-3 d before to 1-3 d after ovulation, then
it disappears gradually. Scanty amount or no fluid accumulation is noticed during the luteal phase
of almost all cycles (Fig. C-92). Ultrasonographic appearances of the uterus at the different days
of the IOP are depicted. Positive correlations are found between the mean serum E2/P4 ratio and
each of the mean scores of the uterine fluid and the mean uterine diameter). A negative correlation
is recorded between the mean E2/P4 ratio and the mean number of uterine cross sections (Fig. C-
93).
UB
Uterine horn
Fig. C-89: Longitudinal section in the uterus of ewe lamb infront of the urinary bladder (UB).
Fig. C-90: Three cross-sections of the uterine horn.
Fig. C-91: Accumulation of fluid in the uterus during estrus (arrow), ewe.
Fig. C-92: No fluid accumulation and increase number of cross-sections (arrows) during diestrus, ewe.
a
7.5
Mean number of uterine cross
7
6.5
sections
6
5.5
5
4.5
4
2 b
Mean diameter of uterine cross
1.8
1.6
sections cm
1.4
1.2
0.8
3.5 c
Mean score of uterine
2.5
1.5
0.5
Mean serum E2/P4 ratio

120
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Days of estrous cycle (0=Ovulation)
Fig C-93: Relationships among uterine diameter (a), number of uterine cross-sections (b), scores for
intrauterine fluid (c) and serum E2/P4 ratio (d) during the interovulatory interval (n=18) in ewe lambs.
Pregnancy diagnosis and fetal development

In an extensive study carried out by the author and his co-workers, a total of 336
ultrasonographic examinations were obtained from the 12 ewes between D 22 and 146 of
pregnancy (experiment 1). The mean duration of pregnancy was 151.2  2.3 days (range 148 –
154 d). The embryo was first detected on D 25.38  1.2 (range 24 – 27 days) (Fig. C-94). The
amniotic vesicle (AV) was firstly detected on D 28 (Fig. C-95). Differentiation of the embryo into
head, body, limbs, and tail was noted on D 38  3.2 (range 35 – 41) (Fig C-96). Ossification was
first observed in the fetal head, ribs, and vertebrae on D 44.86  2.5 (range 42 – 48), 50.25  3.4
(range 46 – 55), and 51.50  2.5 (range 48 – 55), respectively (Fig. C-97). The amniotic fluid
contained no reflecting particles and gave almost black image until D 80.67  11.2, when many
echogenic spots were observed whirling around on it. Definite turbidity was observed by D 103.0
 8.0. The allantoic fluid remained clear without any echogenic partials until D 138.0  9.5, when
few echogenic spots appeared moving within it. Increasing the turbidity of the fetal fluid late in
pregnancy might be due to an increase in the secretion of the respiratory tract and buccal cavity,
which possibly accounts for the increased viscosity and the improved lubricated properties of the
fluid. Time of organization, ossification and change the echogenicity of the fetal fluids might help
in judging the fetal age.
UB
embryo
Fig. C-94: Embryo, 28d pregnancy, ewe.
Embryo
Fig. C-95: Amniotic vesicle (arrow), 35d pregnancy, ewe.

Fig. C-96: Beginning of organization of the embryo (arrow), 38d pregnancy, ewe.
Fig. C-97: Beginning of ossification in the head (arrows), 45d pregnancy, ewe.
Accessibility of the different fetal organs and parts for ultrasonic examinations depends on
the day of gestation. Also, accessibility of the various fetal parts for scanning depends on the
method of examination. Transrectal scanning could be performed efficiently until D 48 of
pregnancy. Beyond this time most of the fetal parts, except the placentomes and fetal head,
become out the range of the ultrasound beam. Trans-abdominal scanning could be done as early
as 24 days after breeding, however, by this time the scanning view is much inferior to that of the
transrectal one. By advancing of pregnancy, the view becomes better and equivalent to the
transrectal one.
The regressions of the various fetal measurements on the GA, with the respective predictive
equations, are presented in (Fig. C-98, C-99, C-100). Except for the placentome diameter, all
regression and correlation coefficients are highly significant (p<0.0001). Fetal age could be
estimated from visual inspection of these figures, but for accurate estimation, references should be
made to the equations, which have been computed with the size measurements as the independent
variate.
2
6 y = 0.002x + 0.0196x - 0.8036 6
2
R = 0.8761 y = 5.0574Ln(x) - 15.34
5 2
5 R = 0.9241
4
AVD (cm)
4
CRL (cm)
3
3 2
2 1
0
1 0 5 10 15 20 25 30 35 40 45 50 55 60
0 GA (days)
Fig C-98: Curve-linear relationship between the fetal crown-rump length (CRL), amniotic vesicle
diameter (AVD) and the gestational age (GA) in Ossimi sheep (n = 12).
y = 0.0399x - 0.743 y = 0.0759x - 2.0282

5 7
R2 = 0.9526 R2 = 0.9354
4.5 6
4
5
3.5
ABD (cm)
CHD (cm)
4
3
2.5 3
2 2
1.5
1
1
0
0.5
0
y = 0.0667x - 2.7415
7 4.5 y = 0.0345x - 1.2052
R2 = 0.8819
4 2
6 R = 0.8048
3.5
3
KIL (cm)
5
2.5
RUL (cm)
4 2
1.5
3
1
2 0.5
0
1 0 20 40 60 80 100 120 140 160
0 GA (days)
Fig. C-99: Linear-relationship between the fetal chest depth (CHD), abdominal diameter (ABD), ruminal length (RUL), kidney
length (KIL) and the gestational age (GA) in Ossimi sheep (n = 12).
2 2
6 y = -0.0006x + 0.1198x - 2.5496 3 y = -0.0002x + 0.0485x - 1.3391
2 2
R = 0.3819 R = 0.8874
5 2.5
EBD (cm)
4
PLD (cm)
1.5
3
1
2 0.5
1 0
0 20 40 60 80 100 120 140 160
0 GA (days)
Fig C-100: Curve-linear relationship between placentome diameter (PLD), fetal eyeball-diameter
(EBD), and the gestational age (GA) in Ossimi sheep (n = 12).
The placentome is the most available structure of the pregnant uterus for ultrasound
examination. It is first observed on D 37.29  5.1 (range 30 - 42) as small slightly elevated
echogenic areas on the surface of the endometrium (Fig. C-101). By this time, its echogenicity
strongly resembles that of the uterus. By advancement of pregnancy, it becomes more echogenic
and brighter, and appears as cup or C-shaped in cross section (Fig. C-102). During the last month
of pregnancy, it becomes less echogenic, while its attached surface appears more echo-intensive.
By this time, it starts to collapse with reducing its lumen, while in areas adjacent to the fetus it
appeared flattened (Fig. C-103).
Fig. C-101: Placentome (arrows), 37d pregnancy, ewe.

Fig. C-102: Placentome, C- shape, 86d pregnancy, ewe.
Fig. C-103: Regression of the placentomes (decrease in size with increasing the ehogenicity of the area), 129d pregnancy, ewe.
The study is the first that incorporates the kidney length (KIL) as a biometric index
predicting the GA in sheep. The fetal kidney could be visualized first by D 73.2  6.3 (range 62 –
76) (Fig. C-104). The echo-poor fluid filled rumen serves as a landmark for the detection of the
left kidney. Early in its detection, the kidney is not clearly distinct, has no sharp demarcation, and
its echogenicity resembles to large extend that of the liver. Later on (from D 90 onwards),
differentiation may be made between the renal medulla containing the more transonic discrete
pyramids separated by septa (columns of Bertin) and the cortex consisting of a uniform
distribution of small discrete low-level echoes (Fig. C-105). Its mean long axis increased from
1.41  0.2 cm on D 76 to 3.61  0.3 cm on D 146. Using the KIL – predicting equation
(experiment 2), a difference of  7 d between the expected and observed fetal age is found in 16
sheep (53.3%) and  14 d in another 14 sheep (46.7%). The difference between the expected and
observed fetal ages is not significant. In Human, KIL is measured by high resolution transvaginal
ultrasonography between 14 and 17 weeks' gestation, and by transabdominal ultrasonography
beyond 18 weeks' gestation. One or both kidneys could be seen in 95% of cases after 20 weeks of
gestation.
Fig. C-104: Early detection of the fetal kidney, 76d pregnancy, ewe.
rumen
Fig. C-105: Longitudinal view of fetal kidney, 102d pregnancy, ewe.
Postpartum uterine involution and onset of luteal activity for sheep in the subtropics
The overall interval for complete uterine involution averages 31.88 ± 1.2 d. The diameter of
the previous gravid horn cannot be estimated by d 3 postpartum for most ewes, because it is too
large to be fitted efficiently on the screen as a whole (Fig. C-106). The diameter decreases rapidly
between d 7 and d 14 pp (>50%), but steadily from d 14 through d 32 pp, P=0.0001, (Fig. C-107).
The time for uterine involution is shorter (P=0.03) for ewes that lamb in February than for those
lamb in June (29.42 ± 1.2 vs 33.85 ± 1.1 d, respectively). The mean diameter of the previous
gravid horn is greater at all postpartum stages for ewes lambed in June than for those lamb in
February, the differences are significant on D 7, 11, 14, 18, 25, and 28 pp (P < 0.05), (Fig. C-108).
The other estimated factors and their interactions have no significant effect on the mean interval to
complete uterine involution.
The proportion of ewes that have luteal activity within 35 d, > 35-42 d, and > 42 d of
lambing are 12.1%, 24.2%, and 63.7% following February lambing; and 53.7%, 36.6%, and 9.7%
following June lambing, respectively, P=0.001. The percentages of ewes that show luteal activity
within the same previous periods are 47.1%, 38.2%, and 14.7% for those with total milk yield ≤
40 kg; and 17.5%, 32.5% and 50% for those with total milk yield > 40 kg, P=0.006.
Uterine horn
Fig. C-106: uterine horn, 7d postpartum, the diameter larger than the screen, ewe.
Uterine horn
Fig.C-107: uterine horn, 18d postpartum, decrease diameter of the uterine horn, ewe.
Fig. C-108: Uterine involution in Farafra ewes following February (n=33) and June lambing seasons (n=41).
Uterine pathology
Pyometra in a ewe
A ewe was examined before slaughtering to exclude the possibility of pregnancy.
Ultrasound revealed the accumulation of an echogenic thick material within the uterine lumen,
however no fetal parts or placentomes could be observed (Fig. C-109). An extra x-ray
examination on the uterus could not show any bony structures within the uterus. After
slaughtering, the uterus showed a collection of thick purulant material.
Hydrometra in a ewe
Hydrometra was observed in one ewe. This case was discovered during a routine
gynaecological examination in a herd of ewes. The ewe was not inseminated or mated before.
Ultrasonography revealed enlarged uterus with hypoecogenic fluid. No fetal parts or placentomes
were visible and only fluid-filled compartments, separated by thin tissue walls, were observed
(Fig.. 11). There was not any vaginal discharge. Examination of the ewe three times with one
week interval, revealed nearly the same ultrasonic picture with little reduction of the fetal fluid.
Later on (after 5 months, Fig.-110), the uterus was reduced in size and the fetal fluid completely
diminished without treatment.
Embryonic loss in a ewe

This case was diagnosed as pregnant 35 days after mating. On the second examination, 2
weeks later, the fetus could not be detected. However, the uterus was enlarged with hypoecogenic
fluid tinged with many hpyerechogenic flakes (Fig. C-111). Threads of the fetal membranes could
be observed floating in the fetal fluid. This picture persisted for a few weeks till the uterus
returned to its normal nonpregnant status.
Pus
Fig. C-109: Pyometra (distention of the uterus with pus), ewe.
fluid
Fig. C-110: Hydrometra (accumulation of clear fluid in the uterus), ewe.

FF
FM
Fig. C-111: Embryonic loss, floating of fetal membranes (FM), and turbidity of the fetal fluid (FF), ewe.
Ultrasonography of the reproductive tract of the Female Camel

Introduction
Most female camels are bred in one season, calve in the subsequent breeding season and
then remain sexually quiescent until the following breeding season, leading to long intercalving
periods and significant economic losses. More often than not, camels having a follicle of 1.0 cm
diameter were mated when they appeared to resent mating. Conversely, females with no follicular
activity in their ovaries were showing clear signs of estrus, like frequent urination, stradling of the
hind leg, mounting other females, and submissive behavior towards an approaching male.
However, they were ignored by the male.
Topography of the reproductive tract

The genital tract of the female camel is located in the pelvic cavity or the caudal part of the
abdominal cavity under the rectum and above the urinary bladder. It has two long horns of T or Y
shape, and a short body. The ovaries are round, oval, or flattened, having many vesicles bulging
outside the ovarian giving it the shape of a bunch of grapes (Fig. C-112).
Fig. C-112: Genital tract and ovary of female camels.

Ovarian follicular dynamics

All camelids are induced ovulators; therefore, if mating does not occur, follicles tend to
regress after initial periods of growth and maturity. The cycle, compared with that of ungulates
and primates, is incomplete, consisting of prooestrus growing follicles, oestrus mature follicles,
and diestrus follicular atresia if mating has not occurred. Studies, using real-time ultrasonography
to monitor ovarian follicular changes, have shown that the follicular wave pattern varies
considerablely between camels, and can be divided into three phases: the growth phase of 10.5 ±
0.5 d, a mature phase of 7.6 ± 0.8 d, and a regression phase of 11.9 ± 0.8 d. In approximately 50%
of the cycles studied, the follicle reached a mature size of between 1.5–2.0 cm in diameter (Fig. C-
113) whereas in the other 50% of the cycles, the follicle continued to grow until it reached a mean
diameter of 4.1 ± 0.2 cm (range = 3.0–6.5 cm) (Fig. C-114). These overgrown, anovulatory
follicles took approximately 18.4 ± 0.8 d (range = 11–33 d) to reach maximum diameter,
remained at the same size for 4.6 ± 0.5 days, and took approximately 15.3 ± 1.1 d to regress.
Fig. C-113: Mature ovulatory follicle, 2 cm, female camel.
Fig. C-114: Enlarged non-ovulated follicle, 6 cm, female camel.

Nevertheless, these follicles did not inhibit the growth of other follicles in the same or
contralateral ovary, which would grow, mature, and ovulate if the appropriate stimulus was
applied. However, various methods have been applied to try and hasten the regression of these
large follicles. For example, camels that had a mature follicle of > 3.0 cm in diameter in their
ovaries were treated with either a single injection of 20 μg buserelin (Receptal) or received daily
injections of 150 mg of progesterone-in oil for a total of 14 d. The results indicated that whereas it
took approximately 22 ± 1.5 d for the overly large follicle to regress in the control group that
received no treatment, these follicles regressed in approximately 14.6 ± 1.3 d in animals injected
with Buserelin and 12.7 ± 1.5 d in those animals that received daily progesterone injections. It
may be speculated that the progesterone therapy suppressed the basal secretion rate of LH from
the pituitary gland, thereby preventing any further growth or maintenance of the follicle. The
mean duration of the oestrous cycle has been reported to be 23.4 days in India, 24.2 days in Egypt,
and 28 days in Sudan. In Saudi Arabia, estrous-cycle durations of 11–30 days have been
observed. Serum estradiol concentration reaches peak values when the dominant follicle measures
1.7 cm in diameter. The optimal time to mate or attempt to induce ovulation is when the growing
follicle measures 0.9–1.9 cm in diameter. Ovulation can occur within 48 h following mating or
intramuscular injection of luteinizing hormone; the left and right ovaries function alternatively. In
the absence of a male, estrous may last for 2 weeks, whereas if copulation occurs on the first day
of estrous, receptivity may disappear after 3 days.
Non pregnant and pregnant uterus

Echotechture of the non-pregnant uterus of female camels resembles that of cattle (Fig. C-
114). It was found that gestation length in the camel is 373–393 days. However, longer and
shorter gestation periods have been reported. Following mating, at least one corpus luteum is
formed (Fig. C-115), secreting a significant amount of progesterone.
Fig. C-114: non-pregnant uterus of female camel in longitudinal and (A) cross sections (B).
Single CL
Double CL
Fig. C-115: Corpus luteum (CL), female camel.
Although both ovaries equally produced ova, pregnancy occurred only in the left uterine
horn. Embryos resulting from fertilised ova in the right horn must have migrated to the left horn
for unknown reasons. The embryotoxic effect associated with the right uterine horn, an alternative
that involves prostaglandin-F2 mediated luteolysis has been suggested. Oestrogens are
continuously secreted during pregnancy in the camel. At mid-gestation, oestrogen concentrations
rise, suggesting continued follicular development during pregnancy.
In early pregnancy, it is difficult to observe the amniotic vesicle of camels, because it is
usually cylindrical in shape, and the fetal fluid is little, and the uterus is relaxed. Between days 14
and 16 of pregnancy, the amniotic vesicle appears in the cross-section of the left horn of the uterus
as non-echogenic star shape area, especially in the apex part of the uterine horn (Fig. C-116).
After day 20 of pregnancy, the embryo can be demonstrated as hyperechoic structure within the
amniotic vesicle (Fig. C-117, C-118, C-119). Between days 22 and 25 of pregnancy, the heart
beats of the embryo could be detected for the first time. By day 50, all fetal parts could be
demonstrated (Fig. C-120). After day 90 of pregnancy, it is often difficult to show the fetus as the
uterus becomes too far to reach by the ultrasound waves (Fig. C-121).
Fig. C-116: Anechoic area in the center of the uterine horn (arrow), two weeks pregnancy, female camel.
Fig. C-117: Cross-section in pregnant horn, the embryo in the center (arrow), 21d pregnancy, female camel.
Fig. C-118: Cross-section in pregnant horn, the embryo hanging in the upper third of the uterus, 32d pregnancy, female camel.
Fig. C-119: Fetus at distal part of the amniotic vesicle, 45 days pregnancy.
Fig. C-120: the fetus at the distal part of the uterus, 90d pregnancy, female camel.
Fig. C-121: The fetus was difficult to display, 120d pregnancy, female camel.
Diseases of the female reproductive tract

In a study carried out by the author, 447 female camels were examined for reproductive
disorders. Based on history, animals were categorized as repeat breeder (RB syndrome, n=343),
refused mating (RM syndrome, n=73) and early embryonic death (EED syndrome, n=31).
Animals were then exposed to rectal examination, vaginal exploration and rectal ultrasonography.
Results showed that endometritis and metritis were the major causes of infertility (57.1%).
Vaginal adhesions were the second important infertility problem (16.1%) and they recorded
frequently in multipara than in nullipara animals. Ovarian cysts (5.3%) and ovarian inactivity
(3.6%) did not represent major infertility problems. Miscellaneous causes of infertility included
anomalies of the genital tract (1.1%), hydrosalpinx (0.5%), and vaginal tumors (0.5%), (Table C-
5).
Ovarian cysts and ovarian inactivity did not represent major problems in examined female
camels. Follicle lutein or hemorrhagic cysts (17/24, 70.8%, Fig. C-122) were noticed more than
the follicle theca cyst (7/24, 29.2%), (P=0.01), (Fig. C-123). The frequency of ovarian cysts
(7/152, 3.3% vs. 19/295, 7.3%) and ovarian inactivity (3/152, 2.0% vs. 13/295, 4.4%) did not
differ significantly between nulli- and multi-para camels, respectively.
Although ovarian cysts have been described in dromedaries (Shalash and Nawito, 1963; El-
Wishy, 1990; El-Khouly et al., 1990), the cystic ovary condition is not well documented as in
cattle or other domestic animals. In fact, the term "cystic ovaries" does not always apply to
Camelidae because some females develop follicular cyst if not bred, as ovulation in these species
is induced (Tibary et al., 2005). Moreover, ovulation failure after adequate mating might be a
cause of repeat breeding in Camelidae. Ovulation rate in a well-managed herd ranges from 80 to
90% (Tibary and Anouassi, 1997; Tibary et al., 2005). Ovulation failure might be caused by
inadequate LH release in response to copulation (Tibary and Anouassi, 1997; Kaufmann, 2005).
In this study, repeat breeding and refuse mating were the clinical symptoms of females with
ovarian cysts.
Fig. C-122: Follicle lutein cyst, 7.5 cm, female camel.
Fig. C-123: Follicle theca cysts, 6cm female camel.
Similarly, ovarian inactivity did not constitute a large proportion of female camel infertility.
The reason for that might be the optimum breeding season in which the current study was carried
out, and during which most animals were cyclic. Actually, this problem is not fully investigated in
Camelidae as in other domestic animals.
Table C-5: Frequency of different clinical findings in various syndromes in female camels examined for reproductive disorders (n=447)
Frequency of Different Clinical Findings in
Clinical findings Various Syndromes n(%)
RB syndrome RM syndrome EED syndrome Total
Endometritis / Metritis 222 (64.7) 18 (24.7) 15 (48.4) 255 (57.1)
Vaginal adhesions 47 (13.7) 19 (26.0) 6 (19.3) 72 (16.1)
Apparently normal 49 (14.3) 6 (8.2) 10 (32.3) 65 (14.5)
genitalia
Ovarian cysts 16 (4.7) 8 (11.0) 0.0 (0.0) 24 (5.3)
Ovarian inactivity 0.0 (0.0) 16 (21.9) 0.0 (0.0) 16 (3.6)
Pregnancy 0.0 (0.0) 6 (8.2) 0.0 (0.0) 6 (1.3)
Anomalies of the genital 5 (1.4) 0.0 (0.0) 0.0 (0.0) 5 (1.1)
tract
Hydrosalpinx 2 (0.6) 0.0 (0.0) 0.0 (0.0) 2 (0.5)
Vaginal tumor 2 (0.6) 0.0 (0.0) 0.0 (0.0) 2 (0.5)
Total 343 73 31 447
RB: repeat breeding; RM: refuse mating; EED: early embryonic death
The most dominant pathology of the uterine tube and ovarian bursa in Camelidae is
inflammation with occlusion or accumulation of fluid in the form of pyosalpinx, hydrosalpinx, or
ovarian bursitis. Rectal palpation and ultrasonography help in the diagnosis of these enlargements
of the uterine tube. In severe cases, the ovary and ovarian bursa may be involved and adhere to
each other (Fig. C-124). However many uterine tube inflammations or occlusions are not noticed
clinically. The fertility prognosis in these cases is guarded to poor because there is no specific
treatment. Surgical ablation in unilaterally affected animals may be considered if the other side is
patent.
Pyometra and mucometra are conditions characterized by an enlargement of the uterus due
to accumulation of varying quantities of fluid (a few milliliters to several gallons), (Fig. C-125).
Pyometra with an open cervix and vaginal discharge is observed primarily in the puerperium
period, it due to a postpartum complication (retained placenta, dystocia, uterine prolapse) resulting
in delayed involution due to infection and accumulation of fluid. Closed cervix pyometra is the
most prevalent in Camelidae, and it is usually associated with cervical adhesions or prolonged
progesterone therapy. Pyometra and mucometra are easily diagnosed by rectal ultrasonography of
the uterus.
Fig. C-124: Ovarian bursitis in female camel

Pus
Fig. C-125: Accumulation of purulent material (pus) in the uterus, female camel with vaginal adhesion.
Ultrasonographic ovum pick-up
Since the late 1970s, embryo transfer has been applied as an additional tool in cattle
breeding program providing an additional means of achieving a higher selection among females.
A variable response to the necessary hormonal treatment and the low numbers and quality of
produced embryos put focus on the possibility of in vitro produced embryos (IVP). Different
methods have been tried in order to retrieve oocytes from live animals. Of these techniques, the
ultrasound-guided transvaginal follicular puncture technique, or ovum pick-up (OPU), has rapidly
become an important part of the in vitro embryo production process for embryo transfers since it
offers a possibility to recover oocytes from highly merited females, not only once, but repeatedly.
The OPU technique comprises several sub-procedures. The animals must be restrained to
minimize the movement, and must be given an epidural injection as analgesia and as a relaxation
for the rectum and the vagina. An OPU device is then inserted into the vagina. The device
contains an ultrasound probe and a puncture-needle system (Fig. C-126, C-127, C-128, C-129).
Through a hand in the rectum, the ovaries are put into position and the needle is introduced into a
follicle via the vaginal wall (puncture) and the content is aspirated (Fig. C-130, C-131). Follicles
larger than 2 mm are punctured and the ova are collected twice a week. Ova are fertilized with
semen from one bull, and transferable embryos are produced. Calculated on a yearly basis, this
would amount to 87 embryos per animal, with an intra-animal variation between 28 and 132. This
new technique may replace MOET (Multiple Ovulation and Embryo Transfer; yearly average of
25 transferable embryos per animal), if the embryo-production via OPU can be performed with
semen from any selected bull.
This procedure allows the repeated production of embryos from live donors of particular
value, and it is a serious alternative to superovulation. Ovum pick up is a very flexible technique.
The donor can be in almost any physiological status and still be suitable for oocyte recovery. A
scanner with a sectorial or convex probe and a vacuum pump are required. Collection is
performed with minimal stress on the donor. The laboratory production of embryos from such
oocytes does not differ from that of oocytes harvested at slaughter as the results after transfer to
final recipients. For other species such as buffalo and horses OPU has been attempted similarly to
cattle, and data will be presented and reviewed. For small ruminants, laparotomy or laparoscopy
seems the only reliable route, so far, to collect oocytes from live donors.
Fig. C-126: Ultrasound – guided ovum pick up machine (scanner, probe and needle, pump).
Fig. C-127: the tip of the ultrasound probe attached with a puncture needle.
Fig. C-128: A sketched diagram showed the orientation of the ultrasound probe and the puncture needle.
Fig. C-129: A sketched diagram showed the location of the ovary and the tip of the probe and the position of the needle (Goddard,
1995).
Fig. 130: animal fixation in a chute and introduction of the probe and needle per vagina
.
Fig. C-131: the tip of needle appears on the monitor of the ultrasound inside the antrum of a follicle.
Chapter II: Male Reproductive Tract Ultrasonography
Ultrasonography of the Male Reproductive Tract of the stallion
The prime sex organs of the stallion are the testes or testicles, of which there are two. Each
testicle is suspended by the spermatic cord that extends from the abdomen to its attachment on the
testicle. The testicles are normally ovoid (like an egg) and will measure 80 to 140 millimeters in
length and 50 to 80 millimeters in width. Each will weigh about 225 grams. The testicles are
housed in the scrotum, which is an out-pouching of the skin. It is comprised of two scrotal sacs—
one for each of the testicles—and it is separated by a septum. The scrotal sacs are located on
either side and in back of the penis. The accessory sex glands in stallion comprise the paired
seminal vesicle, the prostate gland, the paired bulbo-urethral glands, and the paired ampullae. The
seminal vesicles are obviously large, non-lobulated, consisting of funds and a neck. The body of
prostate has two lobes connecting at the neck of the urinary bladder. The bulbo-urethral glands are
large, compact, and round located at the end of the pelvic urethra under the bulbo-cavernous
muscles.
Fig. C-132: reproductive tract of horse: T: testis; TE: tail of epididymid; CM; cremastric muscle; Sc: spermatic cord; DD:
ductus deference; U; ureter; A: ampullae; VG: vesicular gland; P: prostate; BUD: bulbo-urethral gland; CP: crus of the penis; ICM:
ischio-cavernous muscle; RPS: retractor penis muscle; PS: penis shaft; GP: glans penis; UB: urinary bladder; UM: urethral muscle;
BUG: bulbo-urethral gland (Senger, 2003).
Ultrasonographic examination of the scrotal contents

The scrotal contents, including the parried spermatic cords, testes, epididymis, vaginal
cavities, and scrotum can be evaluated by ultrasonography. The size of the testis can be estimated
using measures derived during ultrasound examination. This volume estimate can then be used to
estimate expected daily sperm output from a particular stallion. Examination of scrotal contents
can be performed in standing position. Sedation is usually not necessary prior to the use of
ultrasound. The scrotal contents should be examined manually prior to the use of the ultrasound.
Either a linear or a curve-linear 5 or 7.5 MHz ultrasound transducer can be used for evaluation.
The evaluation should be performed in a systemic way to ensure that all the scrotal structures are
evaluated. The probe is placed vertically on the cranial surface of the testis and passed caudally to
the region of the tail of the epididymis. This results in the appearance a cross section of the
testicular parenchyma (Fig. C-133). At the most cranial position the central vein will be largest
enough to visualize. In addition, the head and body of the epididymis and the spermatic cord can
be evaluated (Fig. C-134). As the probe is passed caudally, the spermatic cord will no longer be
seen, but the body of epididymis will still be present. The head and body of epididymis may be
difficult to visualize because of the small cross-section size. The parenchyma of the testis appears
homogenous. The echodense reflections are due to the connective tissue trabeculae that support
the seminiferous tubules.
Ultrasonographic examination of the internal reproductive organs

Internal reproductive examination are justified when the breeding history or the result of
semen analysis suggest a specific problem. Transrectal ultrasonography in conjunction with
palpation for differentiation abdominal from inguinal retained testes. A 7.5 MHz transducer is
highly recommended. Although stallions are generally not accustomed to rectal palpation, many
tolerate the procedure with minimal restraint. The accessory sex glands are almost entirely within
the pelvis. The rectum is evacuated, and the tract is palpated manually. After application of
coupling gel, the transducer is introduced into the rectum and the beam directed downwards. The
best landmark for finding the accessory sex glands is the prominent tubular urethralis muscle
found on the floor of the pelvis. The pyramid-shaped lobes of the prostate gland are located on
either side of the midline at the cranial border of the urethralis muscle (Fig. C-135). They are
connected to one another by a thin band of prostatic parenchyma, the prostatic isthmus. The
ampullae, the vesicular gland necks, and the bladder neck all converge and pass under the
prostatic isthmus. Although, the glandular parenchyma of the prostate is largely homogenous,
small pockets of secretion may be evident. The amupllae are long narrow tubes just above the
neck of the urinary bladder, the lumen is only evident when it is filled with secretion, the
parenchyma exhibits a homogenous texture (Fig. C-136). In non-stimulated state, the vesicular
gland are almost empty; their muscle surface is less echogenic, making palpation and
ultrasonography more difficult. After sexual stimulation, fluid accumulates in funds, the
echogenicity of muscular folds increase, and the glands are readily identified ultrasonography.
The pelvic urethra runs from the bladder neck to the ischial arch. The bulbourethral glands (BUG)
are paired structure located dorsolateral to pelvic urethra at ischial arch. The BUG is ovoid in
longitudinal section and surrounded by a thin echolucent layer of muscle (Fig. C-137). The
parenchyma is homogenous in the non-stimulated state.
Testis
Central vein
Scrotum
Fig. C-133: Echo-texture of a testis - in cross-sectional view - of a 4 y old horse.

Testis
Fig. C-134: Echo-texture of the testis and the body

of the epididymis, in longitudinal section.
Body of epididymis
Lobes of prostate gland
Fig. C-135: Echo-texture of the lobes of the prostate

gland and the urethral muscle (arrow).
Fig. C-136: Echo-texture of the ampulla of a 4 y

horse (arrow), UB: urinary bladder.
BUG
Fig. C-137: Echo-texture of the Bulbo-urethal gland (BUG) of a 4 year horse.
Ultrasonography of the Reproductive Tract of the Cow-Bull and Buffalo-Bull
Anatomy of the genital tract of the bull

The reproductive tract of the bull consists of the testicles and secondary sex organs, which
transport the spermatozoa from the testicle and eventually deposits them in the female
reproductive tract. These organs are the epididymis, vas deferens and penis, plus three accessory
sex glands, the seminal vesicles, prostate and Cowper’s gland (Fig. C-138).
Fig. C-138: Bull genital tract
Ultrasonic assessment of development of genital tract in bull
Scrotal contents
In a study carried out by the author and his co-workers, the scrotal circumference (SC) and
length and testicular length and breadth were measured by a tape and an ultrasound in 6 bulls
from 3 to 24 months of age. The SC showed rapid increase throughout the study; however the
scrotal length growth rate became lethargic in the second year of age. Testicular length and depth
showed hasty growth in the first year of age but the rate of growth became sluggish with the
advancement of age. Testicular breadth grew in a steady manner along the two years of the
investigation (Table C-6).
A longitudinal image for testis (Fig. C-139) showed moderate echogenicity of the testicular
parenchyma. The mediastinum appeared as a high echogenic line in the middle. The same image
showed the different hyper echogenic testicular tonics. In the same time the cavum appeared
between the parietal and visceral layer of tunica vaginalis as non-echogenic line. A transverse
image of the testis (Fig. C-140) showed the mediastinum as hyper echogenic spot in the middle.
The thickness of tunics, mediastinum, and testicular breadth measurements are presented in
(Table C-7). Tunica albugenia showed a very slow rate of growth during the period of study;
wherever the rate pattern of mediastinum growth was slow from the 3rd till the 9th month, rapid
from 12th till 15th month, then unhurried till the end of the investigation. The breadth of the testis
steadily increased along the study.
Table C-6: Developmental changes in scrotal and testicular dimensions estimated by tape and caliper.
Age Scrotum Testis
(months)
Circumference(cm) Length Length Breadth Depth
(cm) (cm) (cm) (cm)
3 14.00±3.0a 7.50±0.7a 4.94±1.5a 2.14±0.6a 2.35±0.8a
6 19.33±1.0b 12.08±1.6b 7.08±0.5b 3.00±0.6ab 2.86±0.6a
c c
9 26.25±7.2 16.60±1.4 7.50±1.4bc 4.25±1.0bc 4.00±0.0b
12 26.25±3.1c 19.00±3.5d 7.75±0.6bc 4.90±1.0cd 4.63±1.2bc
15 30.00±2.1d 20.00±2.3de 8.23±1.8cd 5.53±0.4de 4.63±1.2bc
18 30.50±1.6d 21.00±1.5de 8.95±1.6cd 5.38±1.0de 5.13±1.4bc
d ef
21 30.00±1.8 23.00±1.2 9.50±1.2d 6.10±0.8e 5.20±1.0c
24 33.60±3.2e 24.00±1.7f 10.24±1.4d 6.20±1.3e 5.25±1.0c
values in the same column with different superscripts letters differed significantly
(P<0.05).
Table C-7: Developmental changes in testis and epididymis estimated from ultrasonographic image.
Age Testis Epididymal
(months) T.A. (cm) Med. (cm) Breadth (cm) Tail (cm)
3 0.20±0.2 a 0.25±0.1a 1.94±0.1a 0.90±0.5 a
6 0.20±0.0 a 0.30±0.1 a 2.43±0.3 b 1.04±0.4 ab
9 0.22±0.1 a 0.35±0.1 a 3.01±0.2 c 1.60±0.1 bc
12 0.22±0.1 a 0.35±0.0 a 3.51±0.8 cd 1.83±0.3 c
15 0.22±0.1 a 0.49±0.1b 4.62±1.2 de 2.23±0.1 d
18 0.23±0.1 a 0.49±0.1 b 4.68±0.4 e 2.54±0.5 de
21 0.25±0.2 a 0.49±0.1 b 5.68±1.0ef 2.61±0.2 ef
24 0.30±0.2 a 0.50±0.1 b 5.75±0.2 f 2.74±0.4 f
values in the same column with different superscripts letters differed significantly (P<0.05). T.A.= tunica albugenia, Med. =
mediastinum
Med
TA
Fig. C-139: Testes of a bull, longitudinal view, 1y old. Med=mediastinum; TA=Tunica albugenia.
Med
TA
Fig. C-140: Testes of a bull, cross-sectional view, 1y old. Med=mediastinum; TA= Tunica albugenia.
The tail of the epididymis image (Fig. C-141) was recorded from oblique plane near the
distal pole of the testis. It is well differentiated from the testicular parenchyma as nearly triangular
area separated with non-echogenic line and has less echogenic appearance than it. The greatest
dimension of tail is recorded in table (2) where it showed a gradual rate of growth along the 24-
month age. Pampiniform plexus appeared on the upper pole of testis where non-echogenic area
containing scattered hyper echogenic spots were present (Fig. C-142).
Fig. C-141: Tail of the epididymis, bull 18 m old, sagittal view.

Fig. C-142: Head of the epididymis and the pampiniform plexus, bull 15 m old.
Internal reproductive organs

Transrectal ultrasonic examination of bull revealed that the bulbourethral gland (Fig. C-
143) which appeared as a fusiform uniformly hyper echogenic structure was embedded in the
bulbocavernous muscle which takes more echogenic appearance. The pelvic urethra appeared in
longitudinal section between the level of bulbourethral gland and the urinary bladder (Fig. C-144).
Its lumen appeared as a non-echogenic line in the middle surrounded by moderately echogenic
urethral muscle. The pars disseminata of prostate (Fig. C-144) represented a hyperechogenic area
between the non-echogenic urethral lumen and the less echogenic urethral muscle. The body of
prostate was continuous with the pars disseminate, and took the same echogenicity (Fig. C-145).
It was located dorsal to the neck of the bladder. The ampullae appeared as two dorsal lines on the
neck of the bladder (Fig. C-146) with non-echogenic linear lumen. The glandular lining appeared
as moderately echogenic line followed by hyperechogenic muscular wall. Seminal glands were
examined beside the ampullae, above the neck of the urinary bladder (Fig. C-147). The glands
appeared irregular in shape, with isoechoic lobes of glandular tissue separated by hypoechoic
regions.
BUG
BCM
PU
Fig. C-143: Bulbo-urethral gland (BUG) covered by bulbocavernous muscle (BCM) at the end of pelvic urethra (PU), bull 15 m old.
Lumen of PU
Fig. C-144: Pars disseminate of prostate covered the lumen of pelvic urethra (PU), bull 15 m old.
Fig. C-145: Body of the prostate dorsal to the pelvic urethra, bull 15 m old.
Amp.
UB
Fig. C-146: Ampulla ductus deference (Amp) dorsal to the urinary bladder, bull 12 m old.
UB
Fig. C-147: Seminal gland (sg) dorsal to the neck of urinary bladder,
bull 10 m old.
The longest dimension of the accessory glands is recorded in (Table C-8). The
measurements reveal that the growth rate of bulbourethral gland is noticed in the last three months
of age where the prostate body and disseminate show rapid growth rate till 12-month of age; then,
the rate become slow. The rate of growth of seminal gland is noticed at the first 9 month of age.
The testicular breadth estimated by sonar is correlated with that measured by caliper. A significant
positive correlation is found between testicular breadth and each of epididymal tail and seminal
gland from 15-month of age. However, the correlation between testicular breadth and each of
bulbourethral gland and disseminate part of prostate starts, somewhat earlier, from 12 month of
age.
Table C-8: Developmental changes in the maximum diameter of accessory genital glands estimated from ultrasonographic image in bull.
Age B.U.G. Prostate Seminal gland
(months) (cm) Disseminate Body (cm)
(cm) (cm)
3 1.21±0.2 a 0.74±0.2 a 0.49±0.1 a 1.09±0.1 a
6 1.27±0.2 a 0.75±0.2 a 0.64±0.1 b 1.12±0.1 a
9 1.55±0.6 ab 0.94±0.2 ab 0.79±0.2 bc 1.56±0.2 b
12 1.53±0.4 ab 1.07±0.1 b 0.85±0.1 c 1.57±0.3 b
b b c
15 1.59±0.1 1.18±0.3 0.85±0.1 1.53±0.2 b
18 1.99±0.4 bc 1.23±0.2 b 0.90±0.2 c 1.60±0.1 b
21 2.05±0.4 bc 1.21±0.1 b 0.93±0.2 c 1.58±0.3 b
24 2.12±0.2 c 1.24±0.3 b 1.00±0.2 c 1.70±0.1 b
Values in the same column with different superscripts letters differed significantly (P<0.05). B.U.G. = Bulbourethral gland.
The genital tract of buffalo-bull is usually smaller than that of cow-bull, except glans penis,
pars disseminate of the prostate and the bulbo-urethral gland, which are larger in buffalo bull. The
echotexture of the testis, epididymis, ampulla, prostate, seminal glands, and bulbo-urethral glands
are similar to that of cow-bull (Fig. C-148, C-149).
Testis in longitudinal section Testis in cross-section

TE PP
HE
Tail of the epididymis (TE) Head of the epididymis (HE) and pampiniform plexus (PP)
Fig. C-148: Echotexture of testes and epididymis of buffalo-bull.
U A SG
SG
Ampulla (A), seminal gland (SG), and urethra (U). Seminal gland (SG).
PDP
BUG
U
U
Pars disseminate of the prostate (PDP) and urethra (U). Bulbo-urethral gland (BUG) and urethra (U).
Fig. C-149: Echotexture of Accessory glands of buffalo-bull.
Ultrasonography of the Reproductive Tract of the Ram
Anatomy of the reproductive tract of ram

The reproductive tract of ram is similar to that of bull, however the testicles are relatively
larger and the body of the prostate is absent in ram (Fig. C-150).
Fig. C-150: Ram reproductive tract.
Ultrasonic assessment of development of the genital tract in ram

In a study conducted by the author and his co-workers, twenty rams were allocated into four
equal age groups: A (6 months, BW: 19.32.8 kg), B (12 months, BW: 28.24.8 kg), C (18
months, BW: 342.8), and D (24 months, BW: 42.77.5 kg). In each group, the mean values of
scrotal circumference (SC), testicular breadth (TB), diameters of bulbourethral gland (BUG), pars
disseminate of prostate (PDP), and seminal glands (SG) were measured by tape and ultrasound,
and then correlated. SC increased rapidly between 6 and 18 months (from 12.32.3 to 243.4 cm,
p<0.001), and non-significantly between 18 and 24 months (from 24  3.4 to 26  2.7 cm).
Similarly, TB increased rashly between 6 and 18 months (from 1.30.4 to 4.40.9 cm, p<0.001),
and slowly between 18 and 24 months (from 4.40.9 to 50.5 cm). BUG increased slowly
between 6 and 18 months (from 0.9  0.4 to 1.10.2 cm) and non-significantly between 18 and 24
months (from 1.10.2 to 1.50.3 cm). PDP remained constant until 12 months (0.60.1 cm), then
increased significantly between 12 and 18 months (from 0.6 0.1 to 0.80.2 cm), to keep constant
again between 18 and 24 months. SG increased non-sufficiently between 6 and 12 months (from
0.73  0.36 to 0.91  0.1 cm), then increased rapidly between 12 and 24 months (from 0.90.1 to
1.70.2 cm, p<0.01). Positive correlations were found between SC, TB, and each of BUG, PDP
and SG (Table C-9).
Table C-9: Correlation coefficient between testicular breadth estimated from ultrasonic images (TBs) and each of that measured by
caliper (TBc), epididymal tail (EpT), seminal gland (SG), disseminate of prostate (PD) and bulburethral gland (BUG)
Age (m) TBsXTBc TBs X Ep T TBs X SG TBs X PD TBs X BUG
3 0.93** 0.20 0.45 0.60 0.65
6 0.71* 0.15 0.24 0.28 0.41
9 0.75* 0.46 0.45 0.65 0.66
12 0.87** 0.50 0.37 0.87* 0.83*
15 0.77* 0.81** 0.82** 0.85* 0.70*
* ** * *
18 0.75 0.90 0.75 0.71 0.89**
21 0.70* 0.88** 0.72* 0.68* 0.85**
* ** ** *
24 0.78 0.78 0.92 0.69 0.87**
* p<0.005
**p<0.001
Echo-texture of the testes, epididymis, and accessory glands are similar to that of bull (Fig.
C-151, C-152, C-153, C-154, C-155).
Fig. C-151: Testes, sagittal view, ram 2y old. Med=mediastinum; T.A.=tunica albuginia
Fig. C-152: Tail of epididymis, ram 2y old.

Fig. C-153: Head of epididymis and the pampiniform plexus, ram 2 y old.
Fig. C-154: Pars disseminate and bulo-urethral gland (bug), ram 2y old.
UB
Fig. C-155: Seminal gland dorsal to the neck of urinary bladder (UB), ram 2y old.
Ultrasonography of the Reproductive Tract of the Male Camel
Anatomy of the male reproductive tract in male camels

The scrotum is located in the perineal region with the testicles directed caudo-dorsally (Fig.
C-156). The scrotal skin tends to be smooth and fine during the height of breeding activity, and
then becomes thicker during the period of sexual inactivity because of decreased testicular size.
The testes of camels are ovoid in shape and are usually descended at birth, but they are very small.
They increase in size at the onset of puberty, but there has been a wide variation in the dimensions
reported. This is probably due to differences in age, breed, and sexual activity at the time of
measuring; but, in general they vary in length from 7 - 10 cm and weigh between 80 -100 g each.
They become enlarged and protrude when the male camels are sexually active in the rutting
season. Testicular size is an important parameter in the evaluation of the breeding potential of
males and can be used to predict daily sperm production because of the high correlation found
between scrotal measurements testicular weight and total sperm production. As in other species,
the epididymis is composed of three distinct parts: the caput (head), the corpus (body) and cauda
(tail). It is located along the dorsal border of the testis with the head curving around the cranial
pole of the testis. In dromedaries, the cauda epididymis is round and well-protruded (about 3 - 4
cm above the respective extremity of the testis). The most important feature is the absence of
seminal vesicles in the Camelidae family . In dromedaries the accessory sex glands are: the
ampullae, the prostate, the bulbo-urethral (Cowper’s glands) and the urethral glands. The size and
weight of the glands are affected significantly by the age of the animal, (tending to reach a
maximum between 10.5 - 15 years) and the season, with a maximum gland weight being recorded
during the breeding season. This is concomitant with the increased activity and weight of the
testis. This suggests that the activities of the accessory sex glands are regulated by androgen
secretion from the testis. The Ampulla - the initial part of the ductus deferens - is small in
diameter and very tortuous, but it thickens and forms the ampulla as it approaches the pelvic
urethra. It averages 18 cm in length with the terminal part embedded in a deep groove located on
the ventral surface of the corpus prostatae. It has been suggested that these glands may play the
role of a sperm reserve before ejaculation. The Prostate Gland : this is the largest and the only
palpable gland in the dromedary. It has two components, a compact and a diffuse part with the
two forming an L shape which lies dorsal to the pelvic urethra. The Bulbo-Urethral Glands: there
are two bulbo-urethral glands which are almond shaped structures that are located either side of
the terminal portions of the pelvic urethra. The Urethral Glands: these are located just behind the
body of the prostate and extend to the level of the urethral bulb before opening into the urethral
lumen via numerous ducts. These glands and the pelvic urethra are richly enervated; these nerves
are responsible for the contraction of the muscle and expulsion of glandular secretion.
Fig. C-156: genital tract of a male camel, UB: urinary bladder; P: prostate; UM: urethra muscularis; IcM: ischio cavernous muscle;
CP: crus of the penis; TE: testis; RPM: retractor penis muscle; PS: body of the penis; SF: sigmoid flexutre; GP: galae penis;
DD: ductus deference (Senger, 2003).
Ultrasonic assessment of development of the genital tract in male camel

A total 21 clinically healthy one-humped male camels aged 1.5 to 12 years, were examined
during the breeding season. Testicular length (TL), breadth (TB), and depth (TD), as well as
epididymal head and tail were measured. The pelvic genitalia including bulbourethral gland
(BUG), prostate, and pelvic urethra were examined using transrectal ultrasonography. The results
revealed that the three dimensions of the testes and eipidydimal tail and head showed significant
increase with the advancement of camel age (p < 0.01). The differences between the peri-pupertal
group and sexual mature one in the epididymal measurements were not significant. The left testes
measurements were bigger than the right ones, but not statistically significant. There were
significant differences between the BUG measurements in all examined groups (p < 0.01). The
differences between pars disseminata of the prostate gland and pelvic urethra in the pre-pubertal
and sexual mature group were significantly different (p < 0.01). It was concluded that
ultrasonography gave appreciable benefits in studying the developmental changes of the testes
and accessory glands of the growing camels. The obtained data could provide a useful tool for
predicting camel puberty and future fertility.
By using ultrasound, the testis of male camels appears brighter than that of the bulls and the
rams (Fig. C-157). The tail of epididymis is small and bright (Fig. C-158). The head of the
epididymis is less distinct. The body of the prostate is discoid; sometime contains cavities filled
with clear secretion (Fig. C-159). The pelvic urethra takes an arched shape at its outlet from the
pelvic cavity (Fig. C-160).
Fig. C-157: testis of male camel, 5y old, longitudinal view.
Body epid
Tail epid.
Testis
Fig. c-158: tail and body of the epididymis, male camel, 5y old.
B prost
UB
Fig. C-159: Body of the prostate (B. prost) dorsal to the urinary bladder, male camel, 5y old.
Fig. C-160: Pelvic urethra of male camel, arched shape, 5 y old.

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Part IV
Ultrasonography of the Eye and Musculoskeletal System
By
Fahd Al-Sobayil (BVSc, MVSc, PhD-USA)
Chapter 1: Ultrasound of the Eye and Orbit
Introduction
Ocular ultrasonography is a relatively simple and valuable noninvasive diagnostic tool that can be
performed for the evaluation of the globe in animals. It provides the veterinarian with important
information about the eye and adnexa which sometimes cannot be obtained with other diagnostic
techniques.
Veterinary ocular ultrasonography has been used since 1968 (Rubin & Koch 1968).
Veterinary ocular disease by using two-dimensional ultrasonography was first described in 1980
(Johnston & Feeney, 1980). The first description of veterinary ocular disease diagnosed by B-
mode ultrasound was in 1985 (Eisenberg 1985, Miller & Cartee 1985). Ultrasonographic
evaluation of the eye necessitates knowledge of both ocular anatomy and ultrasonographic
principles.
Normal Anatomy
-The eyeball consists of three layers (Fig. D-1):
-The external fibrous tunic (sclera and cornea, and the junction of the sclera and cornea or
the limbus). This protective layer with intraocular pressure is responsible for the semirigid shape
of the eye.
-The middle vascular tunic or uvea (iris, ciliary body, and a pigmented vascular structure
called the “choroid”). This layer provides nutrition to the eye.
-The internal nervous tunic (the retina). The intraocular myelinated portion of the optic
nerve forms the optic disk.
-The lens of the eye is covered by the lens capsule, and lies in contact with the caudal
surface of the iris. It has a circular shape in a transverse plane. It is an avascular structure,
receiving nourishment from the aqueous and vitreous humors.
-The eyeball is divided into three chambers:
-The anterior: it is bounded by the cornea and the cranial surface of the iris. The aqueous
humor which is a clear, colorless fluid is present in this chamber.
-The posterior (the smallest): it is bounded by the caudal portion of the iris and by the
anterior lens capsule. It communicates with the anterior chamber through the pupil. The aqueous
humor, which is a clear, colorless fluid, is present in this chamber.
-The vitreous chambers (the largest): they are bounded cranially by the lens capsule and the
caudally by retina. They consist of gelatinous fluid that contains 98% water, mucopolysaccharides
and hyaluronic acid. In addition, the vitreous body is reinforced by a fine network of collagen-
like fibers.
225
-The orbit is a bony cavity bounded by six bones: the frontal, sphenoid, palatine, zygomatic,
maxillary and lacrimal bones. In dogs and cats, the body orbit is incomplete, and the dorsolateral
margin is completed by the orbital ligament.
-The lacrimal gland is located between the dorsolateral aspect of the globe and the orbital
ligament.
-There are seven extraocular muscles that originate from the bony orbit and insert on the
sclera: the dorsal, ventral, medial and lateral rectus muscles, the dorsal and ventral oblique
muscles, and the retractor bulbi muscle.
-The spaces between the extraocular muscles, nerves, and vascular elements are completely
filled with an orbital fat and connective tissue which protects these structures. A cushion of fat lies
in the retrobulbar space surrounding the optic nerve.
Fig. D-1. Illustrated section of the eye
Examination Technique
-Most animals require sedation pre-
ultrasound scanning. With some cases, general
anesthesia can be used. However, relaxation of
the extraocular muscles during deep anesthesia
can cause enophthalmos and third eyelid
protrusion which may impede the examination.
Small retractors may be used to keep the
eyelids open.
-Examinations are conducted while the
animal is sitting, standing or lying in sternal or Fig. D-2. Transducer marker (Scotty, 2005)
dorsal recumbency with the head held steady by
the assistants.
-A 7.5 or 10-MHz transducer is good for ocular examination. A standoff pad may
be used to image the anterior portion of the eye. The transducer contains a marker that
can be used as a guide to determine the scanning planes (Fig. D-2).
There are two basic examination techniques:
Ultrasonography of the Eye and Musculoskeletal System 227
The corneal technique (The transcorneal):

The transducer is positioned directly on the cornea following topical ocular anesthesia (e.g.
tetracaine 0.5% or proparcaine 0.5%) (Fig. D-3). This is the preferred method due to providing
the best quality images by minimizing artifacts and improving resolution of deep structures. In
animals with blepharospasm and ocular pain, an auriculopalpebral nerve block is indicated. The
transducer head is cleaned with the appropriate solution (e.g. alcohol followed by a saline rinse).
After the eyelids are manually separated, the transducer is gently applied to the cornea. Sterile
acoustic gel may be used although the tear film and fluid provided by the topical anesthetic are
usually adequate coupling. In order to avoid potential irritation from the gel, the eye should be
thoroughly washed after the examination. This technique allows the best visualization of the
vitreoretinal and retrobulbar structures. The use of standoff pad is required for imaging the cornea,
the anterior ocular structures, and the lens. Ultrasonographic should be performed with care in
cases when there is imminent corneal perforation.
Fig. D-3. Longitudinal or sagital scan orientation (A) Transducer Position (B) Garaphic depicition of the image plane (Scotty, 2005).
The eyelid technique (The transpalpebral):

The transducer is placed directly on the eyelid coupled with acoustic gel (Fig. D-4). This
technique is easier to perform; however, it creates more artifacts due to the interface between the
eyelid and the cornea. This approach requires the clipping of the hair of the eyelid and the eyelash
to improve image quality. This technique allows adequate evaluation of the vitreous chamber, the
retina, and the deeper orbital structures. A standoff pad is used to image the most superficial
structures of the eye (e.g. the cornea, the anterior chamber, the ciliary body, and anterior lens
capsule). A commercially available standoff pad or a small water-filled or acoustic gel-filled
balloon (e.g. an examination glove) may be used. In general, image quality is definitely inferior
when compared with the corneal technique.
Fig. D-4. The eyelid technique (The transpalpebral) shows that the transducer is placed directly on the eyelid coupled with acoustic gel
-Horizontal transverse (frontal) and longitudinal (vertical) scan planes of the eye should be
obtained during each examination. Some transducers have markers that help to determine the
image orientation (Fig. D-5). The horizontal scan orientation divides the globe into dorsal and
ventral portions. The marker on the transducer points toward the 3 o'clock meridian for the right
eye, and 9 o'clock meridian for the left eye. The longitudinal scan orientation divides the globe
into medial and lateral portions. The marker on the transducer points toward the 12 o'clock
meridian.
Fig. D-5. Left picture: Longitudinal or sagital scan orientation (A) Transducer Position (B) Garaphic depicition of the image plane. Right
picture:Horizontal or transverse scan orientation (A) Transducer position (B) Garaphic depicition of the image plane (Scotty, 2005).
-Ultrasonographic examination of the retrobulbar space can be performed by applying the

transpalpebral or transcorneal approches and examining the structures deep to the globe, or by
placing the transducer over the supraorbital fossa and examining the structures behind the eye.
-The ocular structures are examined in a systemic order: the cornea, anterior chamber, iris
and ciliary body, lens, vitreous, retina, choroids, sclera, and extraocular tissue.
Ultrasonographic Appearance of the Normal Eye (Fig. D-6)

-The eyelids can be imaged with the transpalpepral technique, and they appear as echoic
structures immediately adjacent to the transducer (opaque/white).
-The third eyelid appears as an echoic structure just deep to the ventral eyelid.
-An offset is required to visualize the cornea that appears as an echogenic curvilinear
convex structure immediately deep to the standoff of the transducer (opaque/white). It appears as
two parallel echoic (white) lines separated by an anechoic (black) corneal stroma.
-The anterior chamber is seen as an anechoic (black) area deep to the cornea (between the
cornea and the anterior lens capsule).
- The ciliary body is best seen when the transducer is oriented perpendicular with using a
corneal standoff pad. It is imaged as irregular echoic structures extending centrally from the
periphery of the eye, leaving the pupil in the center.
- The iris is difficult to image, but it can be seen under ideal conditions in intimate contact
with the anterior lens capsule using standoff and a high frequency transducer. It appears as echoic
linear bands continuous with the ciliary body immediately posterior.
- The granula iridica or corpora nigra is highly variable in structure and ultrasonographic
appearance, but is often seen on longitudinal images as an echogenic mass of variable size on the
anterior surface of the iris at the papillary margin. It protrudes into the anterior chamber.
- The posterior chamber is a small anechoic (black) space between the iris and the anterior
capsule of the lens. Generally, the posterior chamber cannot be distinguished ultrasonographically
because the anterior lens capsule is normally very close to the iris and ciliary body.
- Between the iris/ciliary body and the posterior wall of the eye, the only echogenic
structures are the portions of the anterior and posterior lens capsule that fall within the primary
ultrasound beam. The normal lens appears as an anechoic (black) structure surrounded by a thin
convex and concave echogenic (white) line that corresponds to the anterior and posterior lens
capsule, respectively. It is difficult to image the entire lens capsule because its curvilinear surface
leads to peripheral echo dropout due to refraction and reflection of the soundbeam. Orienting the
ultrasound beam perpendicular to the peripheral portions of the lens surface allows complete
visualization of the capsule through multiple images.
- The vitreous chamber is the large anechoic region posterior to the lens.
- The retina, choroids and sclera appear in combination as a semicircular concave echogenic
band surrounding the vitreous, and defining the posterior aspect of the globe. The three wall layers
cannot be individually resolved in the normal state.
Fig. D-6. Horizontal transverse image, normal equine eye. Above A Cornea, A: anterior chamber, B: the iris and the ciliary body, C:
anterior and posterior lens capsular regions, D: vitreous, E: retina-choroid-sclera layers (Whitcomb, 2002).
-The optic disk is usually more echoic than the surrounding posterior ocular wall; it exhibits
shadowing, and usually appears as a slight depression in this surface. Less commonly, the optic
disk may be elevated or flushed with the retinal surface.
-The optic nerve is usually seen as a hypoechoic-to-anechoic, slightly funnel-shaped
structure surrounded by hyperechoic retrobullber fat immediately posterior to the optic disk echo
(Fig. D-7).
-The tissues posterior to the globe (muscle, fat, nervous tissue, and vasculature) have
varying echogenicities.
-The retrobulber fat is triangular –shaped with the base bounded anteriorly by the posterior
wall of the globe, and bordered laterally by the extrinsic ocular muscles which converge toward
the apex of the orbit at the optic canal.
-The extraocular muscles appear homogeneous hypoechoic bands running tangentially
around the sclera and converging toward the optic nerve (Fig. D-7). Fascial planes within the
muscles will appear as bright linear echoes when oriented perpendicularly to the ultrasound beam.
-A V-shaped area is seen if the scan plane is off the optic axis in the vertical plane, since the
optic nerve is no longer in the image plane. The retrobulbar area is bounded by the bony orbit.
-The orbit, as very bony structure, appears hyperechoic and casts a strong acoustic shadow
deep to the bony echo (Fig. D-7).
-The zygomatic salivary gland can be imaged ventrally as a hypoechoic structure on a
vertical scan of the eye, adjacent to the extraocular muscles
-After examination, using either approach, the eye is thoroughly and gently rinsed with
sterile ocular saline to ensure that no acoustic coupling medium is left on the eye.
-Sonographic measurements of the normal extirpated equine eye have been reported; the
mean diameter of the equine eye in an anterior to posterior dimension was 39.4 ± 2.3 mm. The
mean depth of the anterior chamber and the vitreous was 4.22 ± 1.29 mm and 17.37 ± 1.98 mm,
respectively. The mean lens thickness was 11.93 ± 1.10 mm.
Fig. D-7. Normal sonographic appearance of the equine retrobulbar region. This image was obtained with a 6.0-MHz curvilinear transducer
set at 10.0 MHz with a scanning depth of 7 cm. D: Vitreous, F: Optic nerve, G: Extraocular muscles, H: Bony orbit (Whitcomb,
2002).
Abnormalities
Cornea
The ultrasound can be used to diagnose various defects in the cornea such as the corneal
ulcers, corneal integrity, stromal abscess, and corneal edema. In case of corneal ulcer, the cornea
has a pitted appearance in the areas of ulceration. An ultrasound examination should not be
performed in animals with severe corneal ulceration and risk of corneal perforation, or should be
performed with great care. In case of stromal abcess, the sonogram reveals a small hyperechoic
linear echo consistent with a small foreign body surrounded by anechoic to hypoechoic material
(Fig. D-8).
In equine, corneal stromal abscesses may also occur in secondary recurrent uveitis. In
horses with corneal stromal abscesses, the corneal edema, neovascularization, anterior uveitis, and
endophthalmitis are usually present which may make the evaluation of the intraocular structures
difficult. Corneal dermoids have been reported in animals.
It is sometimes difficult to define the depth of the extension of the corneal dermoids before
surgery, and there is a risk of corneal perforation during
keratectomy in cases with full-thickness lesions. To define the extent of the mass before
surgery, ultrasound examination of the cornea with high frequency transducers might be a useful
technique.
Fig. D-8 A corneal stromal abscess in the right eye of a 5-yearold Arabian gelding. You can see a small hyperechoic linear echo consistent
with a small foreign body (arrowhead), surrounded by anechoic to hypoechoic material (large arrows) forming the corneal stromal
abscess. The iris is adhered to the cornea (anterior synechiae). Corneal edema and vascularization made direct visualization of the
abscess difficult (Diaz, 2004)
Iris/ciliary body
Masses in the iris or ciliary body can be diagnosed ultrasonographically as hypoechoic
objects (Fig. D-9).
-Iris prolapse can be seen as a result of both sharp and blunt trauma to the globe, and
secondary to infectious and noninfectious diseases of the cornea. At initial presentation, horses
with iris prolapse show moderate to severe aqueous flare and fibrin formation with hypopion and
hyphema. In case of iris prolapse, the ultrasound examination could be used to examine the
intraocular structures. In this case, the ultrasound examination should be performed
transpalpebrally, and the transducer should be used with extreme care; sense pressure in the globe
may increase the severity of the prolapse.
Synechiae or adhesions of the iris to the cornea (anterior), or the iris to the anterior lens
capsule (posterior), occur secondary to corneal perforation, corneal stromal abscesses, and chronic
uveitis. The iris in anterior synechiae is imaged adhered to the cornea (Fig. D-8). The iris in
posterior synechiae is imaged adhered to the anterior lens capsule. Ultrasound is useful to detect
other ocular abnormalities that might be posterior to the synechiae such as cataracts or retinal
detachment.
Fig. D-9. Ultrasound image of the iris showing hypoechoic mass
The lens
-Both congenital and acquired cataract are common in animals, and can be detected
ultrasonographycally. The image shows an increase in the echogenicity of the lens (Fig. D-10). In
horses, vision is affected in those with complete cataracts or extensive cortical opacification.
-Possible discrimination of general cataract, location, and stage (hypermature and
intumescent cataracts based on a decreased and increased lens size).
-Ultrasonography is useful to detect cataracts in animals with corneal edema or other
opacities that preclude visualization of the lens, or in post-traumatic accidents. Ultrasonographic
examination of cataracts in horses shows echogenic to hypoechoic areas within lens. The lens
capsule is usually rounder and more echogenic than normal. In cases of hypermature cataracts,
hyperechoic areas consistent with mineralization are imaged within the lens. In addition, a smaller
than normal lens diameter and wrinkling of the anterior lens capsule can be detected. There is a
direct relationship between the intensity of the lens echogenicity and cataract stage. Other
intraocular abnormalities including retinal detachment, vitreous degeneration, and hemorrhage
can be detected ultrasonographica-lly in animals with cataracts that may not be identified with
routine ophthalmologic examination. In horses with cataracts, vitreous opacities are frequently
identified and they appear ultrasonographically as echoic opacities in the anechoic vitreous cavity.
These opacities can be consistent with hemorrhage, white blood cells, asteroid hyalosis, fibrin
strands, or vitreal pseudomembranes. The ultrasound can also be useful for the detection of
postsurgical complications of ocular surgery.
Lens subluxation or luxation

It is most frequently seen after ocular trauma, recurrent uveitis, and glaucoma. The
echogenic lens capsule will be seen in an abnormal position either anterior or posterior to its
normal location, or it may appear moving freely between the anterior chamber and the vitreous.
In horses with traumatic luxation of the lens, echogenic loculations or masses in the vitreous or
anterior chamber consistent with hemorrhage or blood clots may be imaged.
Rupture of the lens can occur after ocular trauma or uveitis. In horses, a break in the normal
linear echo produced by the anterior and/or posterior capsule of the lens is detected
ultrasonographically, with echogenic lens material in the surrounding aqueous humor or vitreous.
The lens may appear collapsed or enlarged, and the hemorrhage may be seen within the globe or
lens capsule.
Glaucoma
It occurs in animals. It can develop secondary to ocular trauma, chronic intraocular
inflammation, extensive synechiae, lens luxation, intraocular neoplasia, recurrent uveitis, and
maldevelopment of the filtration angles, among others. Animals with glaucoma show early signs
including corneal edema or striae, lens luxation, and dilation of the pupil. The diagnosis of
glaucoma occurs by measuring the intraocular pressure with tonometr or by histopathologic
examination of the eye. However, ultrasonographic measurement of the size of the globe in
animals with suspected glaucoma can support this diagnosis. In horses with unilateral glaucoma,
the diameter of the affected eye is increased in comparison to the normal contralateral eye. In case
of bilateral glaucoma, it can compare the diameter of the ocular glaucoma with the normal eye.
Ultrasound will help to differentiate between exophthalmos associated with orbital disease or
buphthalmos. Ultrasound may also be useful in determining the etiology of glaucoma (lens
luxation, uveitis, or intraocular neoplasia) or in detecting the associated abnormalities, such as
retinal detachment.
Microphthalmos or congenitally small globe

It can be seen in animals, while phthisis bulbi is atrophy of the globe that occurs after
trauma or chronic uveitis. Ultrasound in microphthalmos shows a small globe that is otherwise
normal. Ultrasound of phthisis bulbi reveals small misshapen globe with smaller than normal of
anterior and vitreal chambers.
Fig. D-10. Congenital cataract in horse

Fig. D-11 Transpalpebral sonogram and post mortem picture of the right eye obtained from a 3-year-old Connemara- Lipizzaner cross filly
with an abscess in the vitreous. (A) Transverse (left) and longitudinal (right) images of the eye. A heterogeneous mass can be
visualized in the vitreous chamber (arrows). This mass has a layer of anechoic fluid and an area with more echoic content. There is
hypoechoic material in the vitreous chamber adjacent to the mass most consistent with fibrin. (B) The mass in the vitreous chamber
was consistent with a chronic abscess (arrows) (Diaz, 2004).
The vitreous and intraocular masses

Opacity of the vitreous can be seen with vitreous degeneration, hemorrhage, inflammation,
asteroid hyalosis, and detachment. Vitreous degeneration is more frequent in older animals, and
can develop secondary to intraocular inflammation with hypermature cataract formation. The
ultrasonographic imaging of vitreous opacities shows areas of increased echogenicity in the
normally anechoic vitreous. The origin of intraocular masses can be inflammatory, infectious,
neoplastic, and cystic. With intraocular neoplasia, ultrasound examination is important to
determine the location, size, shape, extension of the mass, and structures affected. The differences
between cysts and neoplasias can be detected ultrasonographically. The cysts are characterized by
a thin echoic wall with an anechoic center, while neoplasias appear as soft tissue densities.
Intraocular abscesses will appear as discrete masses with a more hypoechoic to anechoic
echogenicity (Fig. D-11). Sometimes the walls of an abscess will not be well defined because of
local inflammatory reaction.
The retina
Retinal detachment has been reported in animals with trauma. Retinal detachments have
been seen ultrasonographically in cases of cataracts, endophthalmic, glaucoma, and as
postoperative complications of phacoemulsification. In horses, the most common cause for retinal
detachment is acute or chronic choroiditis, or equine recurrent uveitis. In cases of acute uveitis, a
complete retinal exudative separation occurs, while in chronic cases, the separation results from
the traction of fibrovascular vitreoretinal strands. During routine ophthalmologic examination, the
detection of complete retinal detachment may be obscured by opacities in the eye as (such as
intraocular masses, lens opacities, fibrinous exudates, and synechia). It is easy to diagnose
complete retinal detachment ultrasonographically (Fig. D-12).
In general, retinal detachment appears as echogenic structures (linear or curvilinear) within
the posterior segment. In many cases, they form the classic "seagull sign" (with the wings
representing the retina, billowing from the remaining anchor point at the ora ciliaris retinae and
the optic disc). If the detachment is partial, a convex hyperechoic line that represents the retina is
seen in the vitreous elevated from the choroid. If the detachment is complete, two echogenic V-
shaped linear structures are imaged in the posterior segment of the globe. These echogenic lines
run from the ciliary body to the optic disc and have a waving motion in the vitreous. In long-
standing detachments, the retina may be more echoic from dystrophic calcification, and the
subretinal space is usually anechoic. Echoic material in the subretinal space is consistent with
hemorrhage or infiltration with neoplastic or inflammatory cells, and it is usually associated with a
worse prognosis. Hemorrhage in the vitreous may also be seen associated with acute retinal
detachment.
Retinal detachment can be differentiated from other vitreal echogenicities, such as vitreal
fibrin strands or pseudomembranes, in the followings:
1- This is accomplished by carefully tracing the linear echogenic structures of the retinal
detachments that remain anchored at optic nerve head.
2- Retinal detachment lesions have more intense echoes.
3- Retinal detachments have more restricted (less movable) lesions in real-time
ultrasonography.
Fig. D-12. retinal detachment. The “wings” are the detached and bullous portions of the retina, spanning from the optic nerve head to the ora
ciliaris retinae. An increased proportion of the lens capsular region is hyperechoic consistent with a cataract (Scotty, 2005)
The tissues posterior to the globe (muscle, fat, nervous tissue and vasculature)
Retrobulbar Masses
-Ultrasonography can be used to diagnose masses such as hematomas, abscesses, and
tumors in and around the region of the orbital cone (Fig. D-13, D-14).
-These masses can be variably composed of fluid (anechoic), soft-tissue (echoic), and
mineral (hyperechoic) regions
-It might be associated with indentation and/or displacement of the globe and disruption of
surrounding bony structures (Fig. D-15, D-16).
Fig D-13. A 22-year-old Welsh pony mare presented for exophthalmos, sonogram of the left eye, and postmortem picture of the left eye. (A)
Notice the bulging of the supraorbital fossa. (B) Sonogram of the left eye revealed a round homogenous discrete soft tissue mass in
the retrobulbar region (arrows). (C) Postmortem examination confirmed a retrobulbar mass (arrows) that was determined to be a
carcinoma histopathologically (Diaz, 2004).
Fig. D-14 Retrobulbar osteoma. (A) Clinical photograph depicting exophthalmia of the right eye in an adult Quarter Horse
mare. (B) Longitudinal image, retrobulbar osteoma. This image depicts a welldelineated mass of mixed echogenicity.
In this case, the mass was also occupying the paranasal sinuses (not shown). The caliper crosshairs are being used to
measure the size of the mass (Scotty, 2005)
Fig. D-15 Transpalpebral sonogram (transverse and longitudinal planes) of the left eye obtained from a 1-month-old Standardbred colt with
a ruptured ocular globe from recent severe ocular trauma. The globe is small with no recognizable intraocular structures and is
filled with anechoic and echogenic material consistent with blood (arrows). The central anechoic structure is most likely the lens.
There is a periocular hematoma and severe soft tissue swelling (arrowheads) that made direct visualization of the globe impossible
(Diaz, 2004).
Fig. D-16 Transpalpebral sonogram of the left eye obtained from a 10-year-old Arabian mare with a history of recent ocular trauma. Notice
the large hyperechoic bony fragment (arrows) casting a strong acoustic shadow indenting the globe (Diaz, 2004).
Chapter 2: Tendons & Ligaments
FLEXOR TENDONS & LIGAMENTS
Palmar (Plantar) Aspects of the Metacarpal (Metatarsal) and Phalangeal Regions
Anatomy
-Tendon is a highly organized dense connective tissue that mostly consists of type I
collagen fibrils embedded in a proteoglycan-water matrix.
-The collagen fibrils are grouped into fibers, and are almost parallel to the long axis of the
tendon with a zigzag arrangment pattern.
The superficial digital flexor tendon (SDFT)

-In the fore-limb, the SDFT tendon originates at the medial epicondyle of the humerus, and
it inserts on the distal aspect of the first phalanx and on the proximal extremity of the second
phlanax and palmar to the collateral ligaments.
-A thick SDFT passes distally through the carpal canal and is surrounded in common with
the deep digital flexor tendon (DDFT) by the carpal synovial sheath.
-At the midmetacarpal region, SDFT becomes thinner and broader. The tendon enters the
digital sheath in the distal metacarpal region and becomes wide and thin.
-The tendon near the fetlock forms a short ring around the DDFT. In this region, both
tendons are bound down in the sesamoid groove by the palmar annular ligament.
-At the distal end of the first phalanx, the SDFT divides into tow branches. One branch
inserts on the distal aspect of the first phalanx, and the other branch inserts in the proximal aspect
of the second phalanx.
-The digital sheath extends to the level of the mid-second phalanx.
SDFT accessory ligament (Superior check ligament)

-It is originates on a ridge on the caudal distal surface of the radius near its medial border.
-In the rear limb, the SDFT originates from the supracondyloid fossa of the femur. The
tendon inserts in the calcaneal tuber and in the first and second phalanx.
-The tendon widens at the point of the hock and its strong band attaches on either side of the
calcaneal tuber along with the tarsal tendons of the biceps femoris and semitendinosus.
-The calcaneal bursa is large, and it lies under the tendon between the SDFT and the
gastrocnemius tendon from the distal fourth of the tibia to the midtarsal region.
-In the proximal metatarsal region, the tendon lies slightly plantar and lateral to the DDFT.
-From the lower metatarsal region and distally, the configuration of the tendon is the same
as that seen in the front limb.
-In the front limb, the entire SDFT can be imaged ultrasonogra-phically with the exception
of the accessory ligament which is poorly recognized. SDFT is easily visualized in the rear limb.
-Generally, SDFT appears slightly less echogenic than DDFT.
The deep digital flexor tendon (DDFT)

-In the front limb, the DDFT originates on the medial aspects of the distal humerus, the
proximal olecranon and the middle caudal surface of the radius and ulna. The tendon inserts on
the palmar aspect of the distal phalanx.
-The tendon is broad in the carpal and proximal metacarpal region; it becomes narrow in the
mid-metacarpal region and again becomes wide in the distal metacarpal region.
-In the distal metacarpal region, the DDFT passes through the ring formed by the SDFT,
and then passes distally over the intersesmoidean ligament in which its shape becomes narrower
and thinner.
-The tendon becomes wider and flatter distally as it travels over the navicular bone.
-In mid-metacarpal region, the DDFT accessory ligament (Inferior check ligament) joins
the DDFT.
-In the rear limb, DDFT originates from the lateral and caudal aspects of the proximal tibia
and fibula.
-The tarsal sheath extends from approximately 5-7.5 cm proximal to the medial malleolus
distally through the proximal one fourth of the metatarsus.
-The insertion of the DDFT is the same as that in the front limb.
-Generally, DDFT appears equal or slightly more echogenic than SDFT. The inferior check
ligament is slightly more echogenic than the DDFT, and it is usually the most echogenic of the
structures evaluated in the palmar metacarpal region. In the rear limb, it is difficult to visualize
the inferior check ligament because of its small size.
The suspensory ligament (SL)

-In the front limb, the SL originates on the palmar aspect of the proximal third metacarpus.
-The proximal palmar of suspensory ligament is irregularly oval in shape with indistinct
edges, and it attaches to the check ligament.
-Distally, the ligament becomes more defined with the widest portion being in a medial-
lateral direction. Further distally, the ligament becomes flatter, broader, and roughly oval in shape.
-At the junction of the middle and distal thirds of the third metacarpus or third metatarsus,
the ligament splits into its medial and lateral branches. As the branches approach their insertion
on the proximal sesamoidian bones, they appear roughly equal in size.
-In the rear limb, the suspensory ligament differs basically in cross-sectional shape from
that in the front limb.
-The echotexture of the suspensory ligament is coarser than that of the flexor tendons, or the
check ligament maybe due to its muscle content.
The Procedure of ultrasound examination

-It is required for the examiner to be familiar with the anatomy of the palmar (plantar)
aspects of the metacarpal (metatarsal) and phalangeal Regions.
-Generally, a 7.5-MHz is used in evaluation of structures of up to 4 cm in depth. Tendon
and ligament examination usually fall within this range.
-The horse should be restrained and sedation is sometimes required
-The hair over a strip of skin (approximately 2 cm wide) on the palmar (plantar) aspect of
the limb overlying the tendons is clipped, shaved, and smeared with gel.
-In order to avoid the variation in the tendon load, the examination should be performed
with the horse standing squarely, and with weight equally distributed.
-The region of examination is divided into zones to help identifying the levels at which
ultrasonograms are scanned (Fig. E-1). Each zone has a thickness of approximately two
forefingers. The other way of identifying the location of scanned area is by determining its
distance from the accessory carpal bone.
A B
Fig. E-1. A) Diagram showing the examination zones at the palmar (plantar) aspect of the metacarpal (metatarsal) and phalangeal Regions.
B) Measuring distance of scanned area from the accessory carpal bone.
-The scan begins in the proximal region and extends distally.

-Each zone should be examined using both horizontal and longitudinal scans; (This can be
performed by changing the orientation of the scanhead).
-The branches of the suspensory ligament can be imaged from the palmar or plantar
surfaces by angling the scanhead laterally or medially, or by placing it directly over each branch.
-In the pastern region, the branches of the SDFT are imaged by rotating the scanhead
medially or laterally through 45○.
-It is recommended to image the opposite limb for comparison and to check for bilateral
lesions.
-The portion of the ultrasonogram lies between the skin and the palmar surfaces of the third
metacarpal (metatarsal) bone, the proximal sesmoids, and the phalangs.
-The skin and subcutenous tissues are seen as a hyperechogenic line and a slightly less
echoic space, respectively.
-The accessory ligament of the DDFT, (inferior check ligament) appears as the most
echogenic of these structures, followed by the DDFT and then the SDFT
-Because it has muscle content, the suspensory ligament has a more mottled appearance.
-In the pastern region, the straight and oblique distal sesmoidean ligaments, the deep digital
flexor tendon, and the superficial digital flexor tendon can be imaged.
At zone 1A (Fig. E-2)

-Ultrasonographic Scanning of zone 1A can be performed in a location just below the
carpus. It extends from approximately 0.5 to 4 cm distal to the base of the accessory carpal bone.
When using the transverse scanning, the SDF is located just below the skin surface (slightly
medially placed) as a relatively less echogenic band that has an oval-shaped. The DDF appears
relatively triangular with more echogenicity. Its lateral border is more rounded. The accessory
(inferior check) ligament (AL) has a rectangular shape with relatively hyperechoic, and it lies on
the dorsal surface of the DDF. The body of suspensory ligament (SL) has a rectangular shape and
it lies on the hyperechoic of the third metacarpal bone (MC3) and appears partially. Anechoic
fluid is present in the carpal sheath (CC) between the dorsal border of the DDF and the palmar
border of the AL. The medial aspect of the carpal sheath is wider than the lateral border.
Fig. E-2. Transverse ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at zone 1A. SDF: Supeficial digital
flexor tendon. DDF: The deep digital flexor tendon. CC: carpal sheath. AL: The accessory (inferior check) ligament. SL: The
suspensory ligament. MC3: the third metacarpal bone.
At zone 1B (Fig. E-3)

-Zone 1B extends from approximately 4-7 cm distal to the accessory carpal bone.
Ultrasonographic Scanning of the proximal third of the metacarpus (zone 1B) is almost similar to
that of zone 1A. However, the SDF is located on the midline over the oval-shaped DDF. The
accessory (inferior check) ligament (AL) has a crescent-shaped as it approaches the dorsal surface
of the DDF. The body of the suspensory ligament (SL) is fully formed. The third metacarpal
bone (MC3) is just visible.
Fig. E-3. Transverse ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at zone 1B. SDF: Supeficial digital
flexor tendon. DDF: The deep digital flexor tendon. CC: carpal sheath. AL: The accessory (inferior check) ligament. SL: The
At zone 2A (Fig. E-4)

-Zone 2A extends from approximately 7-10 cm distal to the accessory carpal bone. In zone
2A, ultrasonographic imaging shows that the SDF has less echogenicity and appears flat. The
DDF has a circular shape. The accessory (inferior check) ligament (AL) blends into the dorsal
surface of the DDF and becomes more echogenic. The AL has a crescent-shape as it approaches
the dorsal surface of the DDF. The body of the suspensory ligament (SL) has variable
echogenicity, and it lies along the surface of the MC3.
Fig. E-4. Transverse ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at zone 2A. SDF: Supeficial digital
flexor tendon. DDF: The deep digital flexor tendon. AL: The accessory (inferior check) ligament. SL: The suspensory ligament.
MC3: the third metacarpal bone.
-The longitudinal ultrasonogram of the palmar metacarpal flexor tendons and associated
ligaments at region between zones 1A and 2A shows a hypoechoic SDF just under the skin. The
DDF appears more echogenic than SDF. Fluid is present in the carpal sheath between the DDF
and AL. The SL arises from the proximal end of the third metacarpal bone and runs along the
hyperechogenic bony surface (Fig. E-5).
Fig. E-5. Longitudinal ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at region between zones 1A and 2A.
SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor tendon. CC: The carpal sheath. AL: The accessory (inferior
check) ligament. SL: The suspensory ligament. MC3: the third metacarpal bone.

-Zone 2B is located in the palmar metacarpus just distal to midway. It extends from
approximately 10-14 cm distal to the accessory carpal bone. The SDF appears as a hypoechogenic
straplike, and it is elongated in the lateral to medial plane. The AL appears thinner, has more
echogenecity, and completely blends into the DDF. The SL has mixed echogenicity and is
widened just proximal to its bifurcation. The SL begins to divide into two branches. The
prominent palmar vessels can be distinguished as anechoic regions between the AL and the SL.
Fig. E-6. Transverse ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at zone 2B. SDF: Supeficial digital
flexor tendon. DDF: The deep digital flexor tendon. AL: The accessory (inferior check) ligament. SL: The suspensory ligament.
MC3: the third metacarpal bone.
-Between zones 2A and 2B, the longitudinal ultrasonography of the palmar metacarpal
region shows a hypoechoic SDF, just under the skin, and a more echogenic DDF. The SL appears
as a distinct structure, and it runs along the hyperechogenic bony surface (Fig. E-7).
Fig. E-7. Longitudinal ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at region between zones 2A and 2B.
SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor tendon. AL: The accessory (inferior check) ligament. SL: The
At zone 3A (Fig. E-8 )

-Zone 3A is located in the distal third of the palmar metacarpal region. It extends from
approximately 14-18 cm distal to the accessory carpal bone. The ultrasonographic scaning of this
region shows a very thin AL (or cannot be seen). The SDF is crescent shaped. The SL is divided
into two branches. The hypoechoic area between the two SL branches and the MC3 represents the
tissues of the palmar pouch of the fetlock.
Fig. E-8. Transverse ultrasonogram of the distal third of the palmar metacarpal region at zone 3A. SDF: Supeficial digital flexor tendon.
DDF: The deep digital flexor tendon. SLbrs: The suspensory ligament branches. MC3: the third metacarpal bone.

-Zone 3B is located just proximal to the proximal sesamoids. It extends from
approximately 18-23 cm distal to the accessory carpal bone. The ultrasonographic scaning of this
region shows that the strap-shaped SDF and the digital sheath (DS) blends into the manica
flexoria (M), a fibrous ring extending from the medial and lateral border of the SDF and
encircling the DDF. A small amount of fluid can be seen in the DS around the DDF. The
hypoechoic regions among the DDF, the MC3 and the SLbrs result from echoes generated by a
connective tissue in the region of the palmar pouch of the fetlock joint.
Fig. E-9. Transverse ultrasonogram at zone 3B in a location just proximal to the sesamoids. DS: digital sheath. SDF: Supeficial digital flexor
tendon. DDF: The deep digital flexor tendon. M: the manica flexoria SLbrs: The suspensory ligament branches. MC3: the third
metacarpal bone.
-At the area between zones 2B and 3B, the AL ends and blends into the dorsal surface of
DDF. The SL begins to split into two branches that pass out of the scan plane.The SDF and DDF
continue toward the fetlock (Fig. E-10).
Fig. E-10. Longitudinal ultrasonogram of the palmar metacarpal flexor tendons and associated ligaments at region between zones 2B and 3B.
SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor tendon. AL: The accessory (inferior check) ligament. SL: The
At zone 3C (Fig. E-11)

Zone 3C is located at the level of the fetlock. It extends from approximately 23-28 cm distal
to the accessory carpal bone. In this zone, the bony shadows of apices of the proximal sesamoid
bones can be seen. The SDF and DDF lie palmar to the sesamoids (SES). The palmar anular
ligament (PAL) of the fetlock is detected as a hyperechoic band just under the skin. The
intersesamoidean ligament (IS) runs between the sesamoids just palmar to the fetlock joint.
Fig. E-11. Transverse ultrasonogram at zone 3C. PAL: the palmar anular ligament. DS: digital sheath. SDF: Supeficial digital flexor tendon.
DDF: The deep digital flexor tendon. SES: the sesamoid bones IS: The intersesamoidean ligament. MC3: the third metacarpal
bone.
At proximal phalangeal zone (Fig. E-12,13)

The ultrasonographic location starts below the ergot distal to the proximal aspect of the
distal condyles of the proximal phalanx (PP). The ultrasonographic location starts below the
ergot. The SDF is a thin band overlying the DDF, and it is surrounded by a synovial fluid in the
digital sheath. The straight distal sesamoidean ligament (SS) and the two oblique sesamoidean
ligaments (OS) are obvious. The proximal phalanx (PP) can be seen as a hyperechoic structure.
Fig. E-12. Transducer selection for imaging proximal phalangeal zone (A), middle phalangeal zone (B & C) and distal phalangeal zone (C &
D).
Fig. E-13. Transverse ultrasonogram at the proximal phalangeal zone. SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor
tendon. DS: digital sheath. SS: the straight distal sesamoidean ligament OS: The two oblique sesamoidean ligament. PP: the
proximal phalanx.
-The longitudinal sonogram shows that a thin of SDF can be detected in which the tendon is
about to divide into two branches. The straight sesamoidean ligament (SS) is detected as a
hyperechoic structure, and the DDF is less echogenic. A small amount of fluid can be seen
between the DDF and the SS. The insertion of an oblique sesamoidean ligament (OS) into the
proximal phalanx (PP) can be detected at this level (Fig. E-14).
Fig. E-14. Longitudinal ultrasonogram at the proximal phalangeal zone. SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor
tendon. DS: digital sheath. SS: the straight distal sesamoidean ligament OS: The two oblique sesamoidean ligament. PP: the
proximal phalanx.
-A recent study has divided this zone into three equal areas (P1A, P1B & PIC) (Fig. E-15).
The DDF has a flattened oval shape at P1A, it begins to show a bilobed appearance at P1B, and it
has a peanut shape at PIC. At P1A and P1B, the straight distal sesamoidian ligament (SDSL)
appears oval to trapezoid-shaped, and it becomes somewhat squared-shaped at P1C near its
insertion onto the proximal of the middle phalanx (P2). At P1A, the SDF begins to form its
branches. Branching is complete at P1B and PIC.
Fig. E-15. Transverse (left) and longitudinal (right) ultrasonographic reference images of the three zones of P1. (A) P1A, (B) P1B, &
(C)P1C.— DDFT: The deep digital flexor tendon. SDSL: the straight distal sesamoidean ligament (Whitcomb, 2009).
DDF injuries may be found throughout P1 and assume many configurations, ranging from
core lesions within one or both lobes (Fig. E-16).
Fig. E-16. Transverse (left) and longitudinal (right) ultrasound images of a core lesion (arrows) within the lateral lobe of the DDFT at the
level of P1C.
At middle phalangeal zone (Fig. E-17)

-The ultrasonographic location is proximal to the distal condyles of the proximal phalanx
(PP). The SDF is split into two branches. The DDF is relatively flat. The straight sesamoidean
ligament (SS) can be detected at this level.
-In recent a study, Whitcomb (2009) has divided ultrasonographic identification of the
middle phalanx. It has been divided by ultrasonographic imaging into four regions A (proximal
middle phalanx), B (mid of middle phalanx), C (distal of middle phalanx), and D (the proximal
flexor surface of the navicular bone) (Fig. E-18). The proximal recess of the navicular bursa can
be evaluated by moving the transducer at the distal aspect of the middle phalanx as far distally as
possible, between the heel bulbs. Fluid is often not visible in normal horses, but it is usually
detected in cases with navicular bursa effusion (Fig. E-19). It can differentiat between the palmar
(plantar) recess of the distal interphalangeal joint capsule and the navicular bursa.The distal
interphalangeal joint capsule is located adjacent to the palmar (plantar) surface of P2 on transverse
and sagittal views (Fig. E-20). In addition, the synovial fluid is visible within the joint capsule in
most horses.
Fig. E-17. Transverse ultrasonogram at the middle phalangeal zone. SDF: Supeficial digital flexor tendon. DDF: The deep digital flexor
tendon. SS: the straight distal sesamoidean ligament. PP: the proximal phalanx.
Fig. E-18: Transverse ultrasonographic images showing the normal appearance of the DDFT at proximal P2 (A), at mid P2 (B), at distal P2
(C), and at the proximal flexor surface of the navicular bone (D). ML, medial lobe; LL, lateral lobe; CSL, collateral sesamoidean
ligament; NB, navicular bone (Whitcomb, 2009).
Fig. E-19: Transverse ultrasound images showing prominent navicular bursa (NB) effusion. Mild to moderate synovial thickening also is
present. The medial and lateral lobes (ML; LL) are within normal limits (Whitcomb, 2009)
Fig. E-20. Transverse ultrasound image at the level of distal P2. The palmar recess of the distal interphalangeal joint (JT) is located adjacent
to P2. The navicular bursa (arrows) is located between the DDFT and the collateral sesamoidean ligament (CSL) of the navicular
bone (Whitcomb, 2009).
At distal phalangeal zone (Fig. E-21)

-The ultrasonographic location is at the level of the proximal interphalangeal joint just
proximal to the heal bulbs. Dorsal to the DDF, the straight sesamoidean ligament and the branches
of the SDF coalesce with the scutum interomedialis (SI) fibrocartilage at the proximal end of the
middle phalanx.
Fig. E-21. Transverse ultrasonogram at the distal phalangeal zone. DDF: The deep digital flexor tendon. SI: scutum interomedialis.
-The longitudinal ultrasonographic scanning shows that the conjunction of the straight
sesamoidean ligament (SS) and scrutum interomedialis inserts onto the proximal eminence of the
middle phalanx (MP). The palmar surface of the medial condyle of the proximal phalanx (PP) is
detected. The DDF continues distally (Fig. E-22).
Fig. E-22. Longitudinal ultrasonogram at the proximal edge of the heel bulb. DDF: The deep digital flexor tendon. SS: the straight distal
sesamoidean ligament. PP: the proximal phalanx. MP: the proximal eminence of the middle phalanx.
In a recent study (Whitcomb, 2009), the solar surface of the hoof can be
ultrasonographically imaged. The solar surface of the hoof should be soaked overnight in water
and then tremmed to be smooth and flat immediately before the imaging. At the widest portion of
the frog, the flexor surface of the navicular bone can be visualized. The navicular bursa is located
between the flexor surface of the navicular bone and the DDFT (Fig. E-23).
Fig. E-23. Longitudinal (left) and transverse (right) transcuneal ultrasound images showing a smooth surface to the flexor surface of the
navicular bone, best shown on the transverse view in this horse. The overlying deep digital flexor tendon is indicated by the arrows.
Note that the navicular bursa cannot be specifically visualized between the navicular bone and the DDFT (Whitcomb, 2009).
The distal sesamoidean impar ligament (IL) extends from the distal border of the navicular
bone to the solar surface of third phalanx. It can be visualized by sliding the transducer toward the
tip of the toe from an image of the navicular bone. The ligament can be recognized on transverse
views as an oval to rectangular structure between the DDFT and the solar surface of third phalanx
and it often appears more echogenic than the DDFT (Fig. E-24).
Fig. E-24: Longitudinal (left) and transverse (right) transcuneal ultrasound images showing a normal insertion of the deep digital flexor
tendon (arrows) onto P3. The distal sesamoidean impar ligament (IL) is visible on the longitudinal view between the navicular bone
(NB) and P3 (Whitcomb, 2009).
Chapter 3: The Joints
Patient Preparation and Scanning Technique

-The hair over the evaluated joint should be clipped or shaved, and the skin should be
cleaned and scrubbed immediately before the application of ultrasound coupling gel.
-A 7.5 to 14-MHz transducer is good for the examination of joints with the smallest depth
such as the joints of the distal limb and the back. For the larger or deeper joints (e.g. shoulder,
elbow, hip, and stifle) or to examine the articular facets, the use of a convex linear array
transducer with a slightly lower frequency (5.0-10.0 MHz) is usually necessary. A rectal linear
array transducer is used to image the ventral aspects of the pelvis and the caudal lumbar
intervertebral spaces, the intertransverse articulations, and the lumbosacral junction.
-The joint should be scanned in its long and short axis. With this approach, the bones above
and below the articulation can be identified. It is easy to locate the collateral ligaments when
moving the transducer cranial or caudal (dorsal or palmar/plantar) until the ligaments are detected
connecting the bones.
Synovial Joint
Anatomy of the Synovial Joint (Fig. E-25)

The synovial joint consists of at least two bone ends covered by articular cartilage. The joint
is surrounded by a joint capsule which is made up of a fibrous capsule (the outer layer) and a
synovial membrane (the inner lining layer). The joint cavity contains synovial fluid that provides
lubrication within the joint itself. The collateral ligaments are important structures located outside
the joint cavity. In some joints, there are also intra-articular ligaments (e.g. the cruciate ligaments
of the femorotibial joint).
Fig. E-25: The structures of a typical normal synovial joint.

The Normal Joint Ultrasonography

-The normal synovial fluid appears anechoic, but it is difficult to be detected except in
periarticular recesses. However, joint effusion can be readily detected by ultrasonography as a
distension of periarticular joint recesses. The examiner should not apply excessive scanning
pressure because this might squeeze out the synovial fluid, making it difficult to detect the
abnormal synovial effusion. The presence of large quantities of uniformity echogenic fluid is
associated with a hemarthrosis, particularly periarticular hematomas.
-Articular cartilage appears as a well-defined thin hypoechoic line overlying a smooth
appropriately shaped bone surface. The cartilage is more obvious in foals than in adult horses
because of its greater thickness. Unfortunately, the curving and opposing nature of the bony
surface prevents the ultrasonographic display of the majority of articular cartilage. However,
flexing of selected joints may allow examining additional areas of the articular cartilage.
-It is difficult to image the normal synovial membrane because it is too thin. However, the
synovial villi can be imaged protruding into the joint space. Synovial membrane can be imaged in
cases with marked thickening (e.g. chronic proliferative synovitis).
-Generally, the fibrous capsule and the collateral ligaments can be imaged
ultrasonographically. With acute joint injuries, the fibrous capsule usually appears more
hypoechoic than normal due to the presence of hemorrhage and edema. With chronic cases, the
joint capsule may appear more echogenic due to fibrosis. Rupture of the joint capsule can be
detected ultrasonographically because of the accumulation of synovial fluid or the formation of a
synovial ganglion. The collateral ligaments tend to have a more variable echogenicity because of
the presence of spiral and crossed fibers, which results in a more heterogeneous echogenicity.
Desmitis of the collateral ligaments of a joint can be easily detected by imaging hypoechoic to
anechoic areas within the ligament with varying degrees of fiber disruption. In addition, collateral
desmitis is associated with bone proliferation or lysis at the origin and/or insertion of the collateral
ligament in the bone. The acute injury that is associated with hemorrhage and edema appears as a
thickened hypoechoic tissue, while the chronic injury that is associated with fibrosis and
dystrophic mineralization often has an echogenic to hyperechoic appearance.
-Examination of the contralateral joint is useful for establishing the normal sonographic
appearance of infrequently evaluated structures.
The Temporomandibular Joint (Fig. E-26)

-In the temporomandibular joint, an echogenic fibrocartilagenous disc that separates the
larger dorsal compartment from the smaller ventral compartment is seen. The disc is attached to
the thin echogenic joint capsule, and it appears as a homogeneously echogenic triangle with its
base laterally. In horses, it measures 2 cm in thickness caudally and caudolaterally, 0.5 cm
rostrolaterally.
-Free synovial fluid is not seen in the normal joint.
-With degenerative joint disease, the temporomandibular joint has narrow joint space, thick
fibrous joint capsule and disintegration of the disc material with replacement of the disc by a
fibrous mass of tissue.
Fig. E-26: Central sagittal section of the equine temporomandibular joint.
Chapter 4: The Neck
-In order to localize the pathological areas of the neck, it is better to perform
ultrasonographic scanning following radiographic and scintigraphic examinations.
-Ultrasonography has been used to evaluate the normal atlanto-occipital joint and the
ultrasound-guided for its injection. Ultrasonographic evaluation of the normal and abnormal
cervical region has been also described (Fig. E-27). Ultrasound-guided intraarticular injection of
the cervical facet joints has been performed in animals.
Fig. E-27: Position of the transducer in relation to the vertebrae. Starting dorsally at the widest point of the articular facet and moving
ventrally
-The cutaneous and subcutaneous layers vary in thickness and appear as a hyperechoic zone
enclosed by more hyperechoic lines. A layer of fat that appears between the subcutaneous and
muscle layers appears as a hypoechoic area. The vertebrae appear as hyperechoic borders
followed by shadowing due to strong reflection from the osseous tissue. The ultrasonographic
scanning of cranal and caudal articular processes vary in size, shape, and outline among different
images of the same facet in different horses and also among different facets in the same horse.
The joint space can be seen, and it varies in size. The large blood vessels can be seen as
hypoechoic structures on the lateral surface of the vertebrae between the articular facet and the
transverse process (Fig. E-28, E-29).
Fig. E-28: Identifiable structures on ultrasound images and anatomical cross-section at the level of C2–C3. Muscles: M. splenius (a-q);
cervical muscles. Vertebral: (A) Processus articularis caudalis; (B) processus articularis cranialis; (D) processus transversus;(E)
corpus vertebra; (F) processus spinosus; (G) crista ventralis. Misc.: (1) Fascia cervicalis; (2) laminae nuchae; (3) funiculus nuchae;
(x) blood vessels of vertebrae; (y) rami from vertebral vessels (Berg et al, 2003).
Fig. E-29: Sonogram of bony proliferative changes at the articular facets ofC5-C6 in a horse with neck pain. Notice the bony irregularities
(arrows) in both the long axis (right) and short axis (left) view of the articulation. Notice the “chair” sign (arrowhead) obtained with
the transducer oriented parallel to the long axis of the vertebral column (right image). The joint is located at the base of the seat
(arrow) ((Reef e et al, 2004).
Chapetr 5: The Fore-Limb
Shoulder Joint
-The shoulder is completely supported by the surrounding shoulder muscles, and it lacks
collateral ligaments. Therefore, all the musculature of the shoulder should be evaluated.
-The biceps tendon that courses over the cranial aspect of the shoulder has a heterogeneous
echogenic appearance in its midportion due to the fat pad that dissects the tendon lobes. The
remainder of the tendon appears homogeneously echogenic. The bicipital bursa that lies below
and around the tendon contains a small amount of visualized fluid (less than 3 ml).
-The infraspinatus muscle onto the caudal eminence of the greater tubercle can be imaged
from the lateral aspect of the shoulder. The infraspinatus tendon is heteroechoic, and it has a bursa
between the tendon and the caudal part of the greater tubercle.
-The joint capsule is thin, and it is best imaged from a lateral and caudolateral view of the
shoulder joint. Synovial fluid of the shoulder joint is not normally imaged. The only visible
articular cartilage in the shoulder joint is the articular margins of the lateral and caudal portions of
the humeral head.
-Generally, synovial fluid of the shoulder joint is not normally imaged. However when it is
imaged, it is most commonly seen from the caudolateral approach below the margin of the
humeral head.
-The most commonly reported abnormalities diagnosed ultrasonographically in the equine
shoulder are biceps tendinitis and bicipital bursitis (Fig. E-30). With acute biceps tendonitis,
hypoechoic to anechoic areas of fiber disruption and enlargement of the biceps tendon have been
imaged in horses.
-Other abnormalities that can be imaged ultrasonographically include adhesions between
the biceps tendon and the bursa, rupture of the biceps tendon, thickening of the bursa with
bicipital bursitis, and bursitis of other locations such as the supraspinatus, infraspinatus, teres
minor, and coracobrachialis. Injection and aspiration of the bicipital bursa can be guided by the
ultrasound.
Fig. E-30: Short and long axis sonograms of the lateral lobe of the biceps tendon in a horse with severe biceps tendinitis. Notice the
heteroechoic appearance of the tendon and the loss of any normal parallel fiber alignment in the long axis view of the tendon (right
image). The more echogenic area in the lateral lobe of the biceps tendon represents an area of organized hemorrhage or clot
(arrows) (Reef e et al, 2004).
Elbow Joint
-The elbow joint is formed between the distal humerus (the trochlea of the distal condyle)
and the proximal head of the radius and the trochlear notch of the ulna.
-The joint capsule is extremely thin caudally, and it forms a pouch in the olecranon fossa.
Cranially, the joint capsule is strengthened by oblique fibers, and on each side it fuses with the
collateral ligament.
-Prolongations of the synovial membrane are extended to the small proximal radioulnar
joints, and they also pouche distally under the origins of the flexor tendons of the digit and the
ulnaris lateralis tendon.
-The synovial fluid is not usually imaged in the elbow joint.
-The articular cartilage of the humeral trochlea appears as a thin anechoic surface between
the distal biceps brachii tendon and the humeral trochlea.
-The medial and lateral collateral ligaments of the elbow joint are large homogeneous
echogenic structures with densely packed parallel fiber bundles that can be followed from their
respective origins on the medial and lateral epicondyle of the humerus to their insertions on the
medial and lateral tuberosity of the radius.
-A zoning system was developed by Tnibar et al. (2001) to facilitate the reading of the scans
of the collateral ligaments and the distal biceps brachii tendon, (Fig. E-31); three zones (A, B, C)
were defined for the lateral collateral ligament; zone A: origin of the ligament from the lateral
humeral epicondyle; zone B: its passage over the humeroradial joint, and zone C: its insertion at
the proximal radius.
-For the medial collateral ligament, four zones were set; zone A: origin of the ligament from
the medial humeral epicondyle; zone B: its passage over the humeroradial joint; zone C: its course
from this joint to the brachialis muscle, and zone D: its passage over the brachialis muscle toward
its insertion at the radius.
Fig. E-31: Cranial view of the equine elbow; the zones used in the sonographic examination of the lateral collateral ligament (LCL) (A,B,C),
the medial collateral ligament (MCL) (A,B,C,D) and the distal bicipital tendon (DBB) (A,B,C) (Tnibar et al, 2001).
-On the horse, it is easy to image the lateral collateral ligament. In general, the ligament is
thickest proximally, widest where it crosses the elbow joint, and thinnist near its insertion. In zone
A, using transverse scaning, the ligament appears ovoid to elliptic in shape, but it is
heterogeneously echoic (Fig. E-32). It has a superficial and a deep portion, with more
echogenicity appearance for the superficial portion. The fiber orientation of the superficial portion
lies craniocaudally on the deep one. In this zone, the craniocaudal width of the ligament is 15-18
mm and its mediolateral thickness is 10-15 mm. Cranial and caudal to the ligament, a hypoechoic
fat structure can be visualized. The antebrachial fascia can be seen as a hypoechoic structure
between the ligament and the skin.
Fig. E-32: Transverse image (A) with corresponding diagram (B) of the lateral collateral ligament (LCL) in zone A. SP, Superficial portion;
DP, Deep portion; AF, Antebrachial fascia; H, Humerus (Tnibar et al, 2001).
-With sagital scaning, the lateral collateral ligament appears heterogeneously echoic at its
origin, and its two portions are well identified and separated from the skin by the hypoechoic
antebrachial fascia (Fig. E-33).
Fig. E-33. Sagittal image (A) with corresponding diagram (B) of the lateral collateral ligament (LCL) over zones A and B. SP, Superficial
portion; DP, Deep portion; AF, Antebrachial fascia; H, Humerus; R, Radius. A transducer with built-in standoff pad was used
(Tnibar et al, 2001).
-In zone B, an echoic elliptic ligament, with thickness of 8-11 mm and width of 20-23 mm,
can be seen crossing the humeroradial joint (Fig. E-34). At the proximocranial and the
proximocaudal aspects of the ligament, the hypoechoic common digital extensor and ulnaris
lateralis muscle are imaged, respectively.
Fig. E-34. Transverse image (A) with corresponding diagram (B) of the lateral collateral ligament (LCL) in zone B. CDE, Common digital
extensor muscle; UL, Ulnaris lateralis muscle; FP, Fat pad; H, Humerus; U, Ulna (Tnibar et al, 2001).
.
-In sagital imaging, the anechoic synovial fluid can be visualized in the elbow joint between
the humeral and radial bones. The ligament crosses the elbow joint (Fig. E-35).
Fig. E-35. Sagittal image (A) with corresponding diagram (B) of the lateral collateral ligament (LCL) over zones A and B. SP, Superficial
portion; DP, Deep portion; AF, Antebrachial fascia; H, Humerus; R, Radius. A transducer with built-in standoff pad was used
(Tnibar et al, 2001).
-In zone C, the ligament becomes flat and takes a crescent shape, and inserts on the lateral
radial tuberosity.The Sagittal images provided better evaluation of the lateral collateral ligament at
this zone. The ligament passes over radial depression and inserts on the lateral radial tuberosity.
-In general, it is difficult to examine the medial collateral ligament ultrasonographically. In
order to achieve this, the horse’s forelimb should be elevated by an assistant during the
examination in a forward position, to make the ligament more accessible to the operator, or that
the limb be placed in extension and reach around the cranial aspect.
-In general, the medial collateral ligament is thick proximally and becomes thinner as it
crosses the humeroradial joint. At its origin, the medial collateral ligament appears elliptic in
shape and echoic with well-defined contour; it fills a depression of the medial humeral epicondyle
(Fig. E-36). The lateromedial thickness of the ligament is 8-10 mm, and the craniocaudal width is
20-25 mm. The anechoic median cubital vein and the hypoechoic pectoralis transversus muscle
are imaged medially to the ligament. When moving the transducer in a caudal direction at the
distal aspect of zone A, the caudal part of the ligament is visualized as an echoic elliptic structure
filling a small medial depression in the epicondyle.
Fig. E-36. Transverse image (A) with corresponding diagram (B) of the medial collateral ligament (MCL) in zone A. PT, Pectoralis
transversus muscle; MV, Median cubital vein; AF, antebrachial fascia; FP, Fat pad; H, Humerus (Tnibar et al, 2001).
-At zone A, using a sagital imaging, the medial collateral ligament appears as a linear
echoic structure with thickness of 8-10 mm and fills the hyperechoic depression of the humeral
epicondyle (Fig. E-37). The caudal part of the ligament can be seen caudally in a small humeral
depression with thickness of 3-4 mm.
Fig. E-37. Sagittal image (A) with corresponding diagram (B) of the medial collateral ligament (MCL) in zone A. PT, Pectoralis transversus
muscle; MV, Median cubital vein; AF, Antebrachial fascia; H, Humerus (Tnibar et al, 2001).
-In zone B, the ligament crosses the humeroradial joint, flattens with increase in its width
(20-24 mm), and decreases in its thickness (approximately 3 mm) (Fig. E-38). The median cubital
vein and the pectoralis transversus muscle are also visualized.
Fig. E-38: Transverse image (A) with corresponding diagram (B) of the medial collateral ligament (MCL) in zone B. PT, Pectoralis
transversus muscle; MV, Median cubital vein; AF, Antebrachial fascia; H, Humerus (Tnibar et al, 2001).
-In zone B using sagital imaging, the medial collateral ligament flattens to approximately 3
mm in thickness and curves across the humeroradial joint.
-In zone C, the ligament is interposed between the hyperechoic radius and the anechoic
cephalic vein and slightly flattens. Toward its distal insertion, the ligament becomes echoic which
thickens slightly to 3-4 mm. It passes over the hypoechoic distal portion of the brachialis muscle
and inserts on the medial border of the hyperechoic radius.
-In zone D, the thickness of the ligament becomes approximately 4 mm; it passes over the
hypoechoic terminal part of the brachialis muscle and inserts on the medial border of the radius
(Fig. E-39).
Fig. E-39. Sagittal image (A) with corresponding diagram (B) of the medial collateral ligament (MCL) in zone D. PT, Pectoralis transversus
muscle; MV, Median cubital vein; BM, Brachialis muscle; R, Radius (Tnibar et al, 2001).
-Over these zones, the antebrachial fascia appers as a hypoechoic structure under the skin.
-Injuries to the collateral ligament and avulsion fractures of its origin have been reported.
The injured collateral ligament is usually enlarged, hypoechoic, and lacking the normal fiber
pattern (Fig. E-40).
Fig. E-40: Sonograms obtained from a horse with desmitis of the lateral collateral ligament of the elbow joint secondary to trauma. Notice
the hetero-echoic appearance of the ligament in short axis (left image) and the loss of the normal parallel fiber pattern in the more
superficial portion of the ligament in the long axis view (right image) corresponding to a new area of fiber damage (arrow) (Reef e et
al, 2004).
Carpal Joint
-Over the dorsal aspect of the carpal joints, the extensor carpi radialis tendon appears as an
echogenic structure with a parallel fiber pattern, and it is surrounded by a synovial sheath
containing a very small amount of anechoic fluid. Both the common and the smaller lateral digital
extensor tendons have synovial sheaths. The sheath of common digital extensor can be imaged
with a small around of anechoic fluid within it, while the lateral digital extensor sheath is not
usually visible.
-All the three carpal joints are surrounded by the joint capsule and collateral ligaments. The
collateral ligaments originate on the styloid process of the radius on both sides. The lateral
collateral ligament extends distally to the fourth and third metacarpal bones. The long, short,
superficial, and deep lateral collateral ligaments are present. The medial collateral ligament
extends distally to the second and third metacarpal bones. The ligament becomes stronger and
wider distally where it attaches to the second and third metacarpal bones. Under the
ultrasonographic examination, the normal collateral ligaments appear as echogenic homogeneous

structures with a parallel fiber pattern.
-Sonographic examination of the medial palmar intercarpal ligament can be performed
when the carpus is held in flexion. The ligament is divided into medial and lateral branches, and
it appears as an echogenic homogeneous structure with rounded and clearly defined margins. The
ligament can appear hypoechoic to anechoic in its central palmar region; the ligament in both
forelimbs has the same thickness whereas there is a wide variation in its width.
-The synovial fluid is not normally imaged in the dorsal aspect of the radiocarpal and
intercarpal joints.
-Injuries to the lateral and medial collateral ligaments (e.g. avulsion fractures and
disruption) can be distinguished sonographically, in addition to some injuries to the medial
palmar intercarpal ligament.
-Injuries of the dorsal articular capsule (e,g, distention and thickening) can be imaged in
horses with traumatic injuries to the joint.
-Tendinitis of the extensor and flexor tendons can be detected ultrasonographically. The
typical ultrasonographic signs of the tendonitis include enlargement of the tendon with anechoic
to hypoechoic areas in addition to a disruption of its fiber pattern.
-With tenosynovitis of the carpal tendon sheaths, anechoic to hypoechoic fluid is imaged,
and the hypoechoic strands of fibrin are often imaged floating within the fluid.
Fetlock Joint
-Ultrasonography of the dorsal joint capsule should be performed when the limb is under
weight-bearing, non-weight-bearing, and in flexion conditions.
-The normal ultrasonographic anatomy of the dorsal aspect of the fetlock joint shows (Fig.
E-41).
-An echogenic joint capsule (except if too relaxed) that varies in thickness in a proximal-to-
distal direction. It measurs in horses 8 to 11 mm at the level of the metacarpophalangeal joint.
-Smooth articular margins can be seen in both the proximal phalanx and the condyles of the
third metacarpal.
-In horses, the normal articular cartilage in the dorsal aspect of the metacarpal or metatarsal
condyle is approximately 1 mm in thickness, and distally it becomes approximately 0.5 mm.
- In horses, the proximal synovial fold of the fetlock joint should not exceed 2 mm in
thickness.
Fig. E-41. Ultrasound scan of normal appearance of the dorsal aspect of the fetlock. 1, Skin; 2, Dorsal capsule; 3, Proximal synovial fold; 4,
Subchondral bone of the condyle of the third metacarpal bone; 5, Articular cartilage of the condyle of McIII; 6, Proximal phalanx.
-No synovial fluid, or only a very small amount of anechoic fluid might be detected in the
normal dorsal synovial recess. In the proximopalmar or proximoplantar recess, a small amount of
anechoic joint fluid is normally imaged in the fetlock joint along with numerous synovial villi.
-The digital extensor tendons (common and lateral digital extensor tendons) have a uniform
echogenicity with a parallel fiber pattern.
-Thickness of the normal palmar anular ligament measures less than 2 mm.
-It is a useful technique to detect tissue injuries including subcutaneous swelling or abscess,
bursitis of the subtendonous bursa of the extensor tendons, extensor tendonitis, capsulitis, synovial
fluid distension of the dorsal recess of the fetlock joint (Fig. E-42), chronic proliferative synovitis,
thining of the articular cartilage of the dorsal and distal aspects of the condyle of McIII, and
subchondral bone lesions.
-In acute synovitis, the ultrasonographic appearance shows thickness in the synovial
membrane, synovial folds, villi oedema and synovial fluid effusion. In chronic synovitis,
ultrasonographic examination shows synovial fold proliferation. In case of non-septic synovitis,
the joint fluid is typically anechoic. In cases of haemarthrosis, ultrasonographic features
hypoechoic or cellular appearing fluid may be seen. In cases of septic joint, the ultrasonographic
features include an obvious effusion with hypoechogenic to echogenic joint fluid and a thickened
synovium.
-In cases of a capsulitis, the dorsal joint capsule appears hypoechoic, swollen, and usually
asymmetric (lateral or medial).
Fig. E-42. A–D. Ultrasonographic images of the dorsal aspect of the fetlock joint. (A) Reference image with a normal homogeneous capsule.
(B) The dorsal pouch of the fetlock joint is filled with an increased amount of anechoic fluid (7) with a normal capsule and synovial
fold, representing a synovitis. (C) The dorsal joint capsule is thickened and has a heterogeneous echogenicity, compatible with a
capsulitis. (D) The synovial fold is thickened and round. The dorsal pouch of the fetlock joint is also filled with anechoic fluid. These
findings indicate a chronic proliferative synovitis. 1, third metacarpal bone; 2, proximal phalanx; 3, joint space; 4, dorsal joint
capsule; 4a, synovial fold; 5, common digital extensor tendon; 6, subcutaneous tissue; 7, synovial fluid (Vanderperren & Saunders,
2009).
-In the dorsal aspect of fetlock, swelling of the subcutaneous tissue may be due to oedema,
haematoma, abscess, or periarticular fibrosis. In cases of edema, haematoma or abscess,
ultrasonographic examination shows a diffuse or localised hypoechoic or anechoic areas between
the skin and the superficial aspect of the dorsal joint capsule (Fig. E-43). In case of fibrosis or old
haematomas, hyperechoic images can be seen ultrasonographically.
Fig. E-43:. Ultrasonographic image of the dorsal aspect of the fetlock joint. There is a diffuse hypoechogenic area between the skin and the
common digital extensor tendon and the joint capsule of the fetlock joint. This represents fluid accumulation and puncture led to the
diagnosis of an abscess. 1, third metacarpal bone; 2, proximal phalanx; 3, joint space; 4, dorsal joint capsule; 5, common digital
extensor tendon; 6, abscess; 7, subcutaneous tissue; 8, skin (Vanderperren & Saunders, 2009).
-Villonodular synovitis can be diagnosed by detecting a thickened (normal thickness <4

mm ) dorsal synovial fold (Fig. E-44, E-45). In case of acute villonodular synovitis, the synovial
fold appears diffusely hypoechoic. A case of chronic villonodular synovitis shows increased
echogenicity of a thickened fold deep to the echogenic dorsal joint capsule and adjacent to an
anechoic region in the dorsal pouch of the fetlock joint, with a rounded distal margin or
hypoechoic regions within the fold. It has been shown that villonodular masses are as large as 2.3
cm (width), and 1.6 cm (thickness) have been imaged.
Fig. E-44:. Ultrasound scan of the dorsal aspect of the fetlock joint. An abnormal synovial fluid accumulation appears between the capsule
and articular surface (Synovial fluid effusion) . 1, Skin; 2, Dorsal capsule; 3, Proximal synovial fold; 4, Subchondral bone of the
condyle of the third metacarpal bone; 5, Articular cartilage of the condyle of McIII; 6, Synovial fluid; 7,Proximal phalanx (Denoix,
2003) .
Fig. D45: Ultrasound scan of the dorsal aspect of the fetlock joint affected with chronic proliferative synovitis.. An abnormal hypoechogenic
mass appears between the capsule and the condyle of the McIII bone. The proximal aspect of the condyle is irregular indicating
bone lysis (arrowhead) 1, Skin; 2, Dorsal capsule; 3, very thick and echoic proximal synovial fold; 4, Condyle of the McIII bone; 5,
Synovial fluid (Denoix, 2003).
-Hypoechoic to echogenic thickening of the dorsal articular capsule of the fetlock joint is
usually asymmetrical, and it is usually located at the dorsal aspect of the metacarpal condyle.
About 36% and 19% of horses with lameness referable to the fetlock joint are related to
hypoechoic areas in the joint capsule and synovial membrane thickening, respectively.
-Examination of the dorsomedial and dorsolateral aspects of the fetlock joints is useful for a
complete evaluation of the articular margins which are smooth in a normal joint.
-The most common abnormal finding is the presence of periarticular osteophytes that can be
examined using this aspect.
-Other injuries that can be detected such as subcutaneous lesions (fibrosis, swelling) and
capsulitis.
-Examination of the medial and lateral aspects of the fetlock joint
-The medial and lateral collateral ligaments have superficial (long) and deep (short) layers.
-The superficial (long) and deep (short) medial and lateral collateral ligaments originate
from the distal lateral and medial epicondyles of the metacarpus or metatarsus and insert onto the
proximal lateral or medial eminences of P1. They appear as a homogeneous echogenic structures
with a parallel fiber pattern.
-The deep (short) collateral ligaments originate from the medial and lateral epicondylar
fossa and courses distopalmarly to insert on the abaxial surface of the medial and lateral proximal
sesamoid bone and palmar or plantar surface of the proximal phalanx. They are oriented
obliquely and thus appear more hypoechoic, and are more difficult to follow sonographically.
-The long superficial collateral ligaments are echogenic. They originate from the distal
lateral and medial epicondyles of the metacarpus or metatarsus, and insert onto the proximal
lateral or medial eminences of P1.
-Collateral ligament injuries are common in the fetlock joint. In general, the affected
collateral ligaments appear enlarged, hypoechoic, and they usually demonstrate a diffuse area of
fiber damage (Fig. E-46).
Fig. E-46: Ultrasonographic image performed at the medial aspect (A) of the left metatarsophalangeal joint of a filly. The superficial and
deep parts of the medial collateral ligament are thickened and hypoechoic. Both parts show a complete loss of fibre structure. These
findings are compatible with a rupture of the superficial and deep parts of the medial collateral ligament. (B) Image of a normal
collateral ligament of the fetlock joint. 1, third metatarsal bone; 2, collateral fossa; 3, joint space; 4, proximal phalanx; 5, superficial
part of the collateral ligament; 6,deep part of the collateral ligament (Vanderperren & Saunders, 2009).
-With chronic or old collateral ligament injuries, enthesophytes are frequently detected at
both their origin and insertion (Fig. E-47, E-48).
Fig. E-47: Above: Tranverse ultrasound scans of the normal lateral (L) and injured medial (M) aspects of the fetlock joint. The affected
medial collateral ligament is enlarged, hypoechoic, and demonstrates a diffuse area of fiber damage. Below: Longitudinal
ultrasound scan of the medial aspect showing the thickening and architectural alterations of the medial collateral ligament. 1, Skin;
2, Collateral ligament; 3, Condyle of the McIII (Denoix, 2003)
-In addition, avulsion fractures of the origin or insertion of these collateral ligaments,
dystrophic mineralization, hemorrhage, exostoses on the contours of the bone, and osteochondral
fragments have been imaged. Approximately 21% of horses with lameness localized to the
fetlock joint region have collateral ligament desmopathy.
Fig. E-48: Sonogram of the lateral collateral ligaments of the metatarsophalangeal joint obtained from a horse with a traumatic injury to the
hind fetlock. Notice the bony fragments embedded in the synovium (arrows). The normal fiber pattern of the superficial long and
short oblique lateral collateral ligaments is absent. Only a few ligamentous fibers are recognizable (Reef et al, 2004).
-Examination of the palmar aspect of the normal fetlock joint shows:

-In normal fetlock joint, a small amount of anechoic synovial fluid in the proximopalmar
recess can be detected.
-In horses, abnormal findings observed in affected fetlock joints include synovial fluid
distention, often associated with enlarged synovial folds (synovitis). Ultrosonographically, it
appears as a large amount of anechoic synovial fluid inside the joint (Fig. E-49).
-Appearance of small echogenic material in the synovial fluid may represent fibrin or
cartilaginous debris.
-Appearance of large echogenic masses in the synovial fluid may represent osteochondral
fragments.
-A homogenous increase in echogenicity of the synovial fluid may represent hemarthrosis
or infectious synovitis.
Fig. E-49: Ultrasound scan of the palmarolateral aspect of the fetlock joint showing an abnormal synovial fluid distension of the
palmaroproximal recess (Synovial fluid effusion) of the fetlock. 1, Skin; 2, Synovial fluid; 3, Synovial membrane and villi (Denoix,
2003).
-The normal palmar/plantar annular ligament is associated with the underlying digital
sheath, and it can be traced from its attachment on the abaxial surface of the sesamoid bones. In
horses, the normal palmar annular ligament measures 2 mm in thickness (in horses).
-Ultrasonography is an excellent modality to show the presence, exact location (lateral/
medial or intra/extra-articular) and amount of equine fetlock fragments. It may show an area of
thickened cartilage. It defects in the articular cartilage and underlying subchondral bone or in
osteochondral fragment that appears as hyperechoic lines or spots, usually lying in a more
superficial position than the rest of the articular margin or subchondral bone from which they are
separated by anechoic gaps. In cases of dorsal P1 fragments, a thickened proximal synovial fold
can be present.
-In the joint capsule, synovial fold of the proximal recess, or free within the fetlock joint
first phalanx, dystrophic mineralization, osteochondral fragments, or small fracture fragments are
seen as hyperechoic areas that are usually associated with the first phalanx (Fig. E-50). Fracture
fragments have been imaged in 12% of horses with disease referable to the fetlock joint with
abnormal dorsal articular margins in 17%.
-In horses with degenerative joint disease, Lysis and bony proliferative change can be
imaged on the proximal border of the metacarpal condyle and on the proximal border of P1 in
horses. Diagnostic ultrasound is more sensitive than radiography for the detection of the bony
irregularities on the proximal border of P1.
-Ultrasonographic examination of the intersesamoidean desmitis shows hypoechoic to

anechoic areas of fiber disruption within the intersesamoidean ligament (Fig. E-51). In horses
with intersesamoidean desmitis, it is common to detect lysis along the attachment of the
intersesamoidean ligament to the axial surfaces of the sesamoid bones.
Fig. D50: Sonograms obtained over the dorsal aspect of the metacarpophalangeal joint demonstrating the marked thickening of the
proximal synovial fold. Notice the bony proliferative change or fracture fragment along the distal metacarpus in the long axis image
(arrow). If this hyperechoic structure casting an acoustic shadow is distracted from the underlying bone in two mutually
perpendicular planes, it is consistent with a fracture, rather than proliferative bone.
Fig. E-51 Sonograms of the intersesamoidean ligament obtained from a horse with an acute onset of lameness referable to the
metacarpophalangeal joint. Notice the hypoechoic area of fiber disruption in the intersesamoidean ligament (long arrow) visible in
the long axis scan (right image). This area of injury is also visible in the short axis image adjacent to the medial sesamoid bone as a
hypoechoic area (short arrow) (Reef et al, 2004).
Pastern Joint
-In horses, the collateral ligaments of the pastern joint originate from the lateral and medial
eminences and the adjacent distal depressions of the distal end of the proximal phalanx, and insert
on the lateral and medial eminences of the proximal end of the middle phalanx. There are also
strong palmar/plantar ligaments of the pastern joint: the central pair originates on the
palmar/plantar of the mid-portion of the proximal phalanx, and the second pair located more
proximally and abaxially. Both palmar ligaments insert on the proximopalmar/proximoplantar
aspect of the second phalanx. The insertions of the central ligaments blend with the insertions of
the superficial digital flexor tendon and the straight distal sesamoidean ligament. In the mid-
pastern region, the combined thickness of the skin, the subcutaneous tissues, and the proximal
digital annular ligament is 2 mm. Ultrasonographically, the collateral ligaments appear as
homogeneously echogenic structures with a parallel fiber pattern.
-Joint fluid is not normally imaged in the pastern joint.
-Desmitis of the collateral and the palmar/plantar ligaments of the pastern joint have been
imaged ultrasonographically (Fig. E-52). Hypoechoic core lesions within the collateral ligaments
have been reported more frequently than diffuse lesions. In addition, enthesophytes and avulsion
fractures can be detected at the origin or the insertion of the collateral and the palmar/plantar
ligaments of the pastern joint.
Fig. E-52 Sonograms of a severely disrupted abaxial ligament of the proximal interphalangeal joint in a horse with severe desmitis of the
lateral plantar ligament of the proximal interphalangeal joint. Notice the marked enlargement of the ligament, its diffuse decrease in
echogenicity, and complete loss of any normal parallel fiber pattern (arrows) (Reef et al, 2004).
The Foot (Coffin Joint)

-The collateral ligaments of the coffin joint originate in the depressions on the lateral and
medial side of the distal part of the middle phalanx and widen distally to insert on the abaxial
depressions on the extensor process of the third phalanx and the dorsal aspects of the collateral
cartilages. At the level of the coronary band, the collateral ligaments are located approximately 2
cm medial or lateral to midline. In horses, the cross-sectional area of the medial and lateral
collateral ligaments of the coffin joint is 0.63 and 0.62 cm, respectively.
-The palmar/plantar part of the coffin joint can be imaged from the palmar or plantar
surface of the pastern. It appears as a small anechoic space immediately proximal to the navicular
bone and dorsal to the collateral sesamoidean ligaments of the navicular bone.
-The dorsal part of the coffin joint can also be imaged just above the coronary band on the
dorsal midline. An anechoic fluid is usually imaged in the dorsal recess of the coffin joint.
-The navicular bone, the navicular bursa and the collateral ligament of the navicular bone
can be imaged between the bulbs of the heel with a high frequency transducer containing a curved
footprint.
-The navicular apparatus can be imaged through the transcuneal approach after soaking the
foot in wet bandages overnight and trimming the frog. The ultrasound scans are performed with a
7.5 MHz sector scanner transducer, a 6.0 MHz microconvex, or a 7.5 MHz linear array transducer
can be used for examination.
-The impar ligament is a short wide ligament that originates from the distal sesamoid bone
and insertes in the distal phalanx. It has a normal cross-sectional area of 0.22 cm2 and measures 2
to 3 mm in thickness.
-The deep digital flexor tendon appears hypoechoic, and it has an echgenic appearance
when the ultrasound beam can be oriented perpendicular to the long axis of its fibers. The cross-
sectional area of the deep digital flexor tendon is 0.47 cm2 and a width of 0.36 cm.
-Changes of the flexor surface of the navicular bone (protrusions of the hyperechoic bony
surface, lysis of the bone and fractures) have been detected ultrasonographically using the
transcunean approach (Fig. E-53).
-Mineralization of the deep digital flexor tendon near its insertion onto the third phalanx and
within the impar ligament shows hyperechoic areas.
Fig. E-53 Transcuneal sonograms of navicular bone, bursa and deep digital flexor tendon in a horse with navicular disease. Notice the
irregular flexor surface of the navicular bone (arrows) and the distended navicular bursa (Reef et al, 2004).
Chapter 6: The Back
-The ultrasonographic imaging of the back is better to be performed following radiographic

and scintigraphic examination in order to localize the pathological areas.
-Ultrasonographic imaging of the superficial aspect of the supraspinous ligament shows a
uniform echogenic band, that its fibers are parallel to the skin. In its deeper portion, the ligament
becomes progressively more hypoechoic due to its obliquity near the interspinous spaces.
-The interspinous ligament appears hypoechoic due to its oblique caudoventral orientation.
-In horses, supraspinous desmitis is more frequently detected between T15 and L3.
-In both acute and chronic desmitis, thickening of the supraspinous ligament can be seen
over the dorsal spinous process or slightly caudally. In case of acute supraspinous desmitis,
hypoechoic areas are usually detected in the intermediate or the deeper portions of the ligament.
In case of chronic supraspinous desmitis, hyperechoic areas with an abnormal fiber pattern are
usually imaged in the dorsal portion of the interspinous space.
- Ultrasonographic examination can be used to image the attachments between the
supraspinous ligament and the bony irregularities at the dorsal spinous process.
- An ultrasonographic lesion of the interspinous ligament that is associated with back pain
shows a periarticular bony proliferation that involves the lumbar articular facets (Fig. E-54).
Fig. E-54 The dorsal spinous processes at T11-T12 and T12-T13 in a horse with chronic back pain. You can see the bony proliferation at the
insertion of the interspinous ligaments onto T12 and T13 (arrows) (Reef et al, 2004).
Chapter 7: The Pelvis
-The sacroiliac ligament consists of two portions: the dorsal and ventral. The origin of the
dorsal portion of the sacroiliac ligament is from the tuber sacrale and the insertion is on the tops of
the dorsal spinous processes of the sacrum. Ultrsonographically, the dorsal portion appears as a
thick echogenic oval structure. In Thoroughbreds and Quarter horses, the mean cross-sectional
area of the short dorsal sacroiliac ligament is 1.1 cm2.
-The ventral portion originates from the tuber sacrale and the caudomedial border of the ilial
wing, and inserts on the lateral sacral crest. In the ultrasonic examination, the ventral portion
appears as a thick, echogenic triangular sheet of ligamentous tissue. The ventral portion of
sacroiliac ligament is attached to the ventral aspect of the articular surface and blends ventrally
and caudally with the sacrosciatic ligament. The contents of the vertebral canal can be imaged
through the space between L6 and S1.
-The ultrasonic can detect the intervertebral disc at the lumbosacral space as an echogenic
structure with a triangular ventral portion and a more rectangular central portion (3 mm in
thickness), while in the caudal lumbar region, only the ventral triangular portion of the disc is
consistently imaged.
-Desmitis of the dorsal sacroiliac and supraspinous ligaments causes loss of normal
echogenicity and a decrease in parallel fiber pattern.
-Enthesophyte or a fracture of the tuber sacrale and dorsal spinous processes can be
detected ultrasonographically.
-Variations in the echogenicity can be seen in the abnormal intervertebral discs. With fiber
rupture, disc cavitation, or healing tissue, focal hypoechoic areas are imaged. With fiber
degeneration or disc fissures, a diffuse loss of echogenicity is seen. Hyperechoic areas indicate
either vertebral body avulsion fractures or dystrophic mineralization.
Chapetr 8:The Hind-Limb
Hip Joint
-In horses, the greater trochanter of the femur and the outer portion of the acetabulum can
be imaged ultrasonographically, but the deeper portions of the hip joint are not visible
ultrasonographically.
-Fractures of the greater trochanter and acetabulum have been diagnosed sonographically.
-Rectal ultrasonography of the pelvis is useful in the diagnosis of fractures involving the
hip.
Stifle Joint
Femoropatellar Joint
-In horses, the patellar (medial, middle, and lateral) ligaments can be imaged from origin to
insertion. They appear homogeneous echogenic with a parallel fiber pattern and vary in shape.
-A large fat pad can be seen in the distal portion of the stifle separating the distal portion of
the patellar ligaments from the synovial membrane.
-A small amount of synovial fluid with anechoic appearance is usually imaged in the
normal femoropatellar joint caudal to the medial and lateral patellar ligaments.
-The synovial villi are usually imaged in the medial recess of the femoropatellar joint.
-The subchondral bone surface of the femoral trochlea appears as a regular hyperechogenic.
-The articular cartilage is thicker over the lateral trochlear ridge (2-3 mm) compared with
the medial trochlear ridge (1-2 mm).
-Patellar desmitis can be diagnosed ultrasonographically. Injury to the medial patellar
ligament, following surgical transaction, usually results in the ligament measuring two to three
times its normal size (Fig. E-55). Spontaneous injury often involves the middle patellar ligament.
Usually a discrete area of fiber tearing (core lesion) is imaged within this ligament, although
diffuse injuries have been described.
Fig. E-55 An enlarged medial patellar ligament from a horse with severe chronic medial patellar desmitis one year after a medial patellar
ligament desmotomy. You can see the marked enlargement of the medial patellar ligament, the heteroechoic appearance of the
ligament, and the loss of much of the normal fiber pattern (large arrows). A small area of parallel fibers is imaged in the more distal
portion of the medial patellar ligament (small arrow) (Reef et al, 2004).
-Ultrasonography provides information about the extent of osteochondrosis lesion on the

trochlear ridges, the size of the osteochondral fragments, and the severity of alteration of the
subchondral bone.
Medial and Lateral Femorotibial Joints

-The medial and lateral collateral ligaments extend from a recess in the distal femur to the
proximal tibia. The medial collateral ligament is 4 to 5 mm thick and is attached to the medial
meniscus, while the lateral collateral ligament is 6 to 9 mm thick at the femorotibial joint space,
and it is separated from its meniscus by the popliteal tendon. The medial collateral ligament and
the medial meniscus are homogeneously echogenic.
-The medial and lateral meniscus have a triangular radial section with the apex oriented
toward the axial portion of the joint. The lateral meniscus has a more trapezoidal shape with 13 to
18 mm thickness at its abaxial border. The attachment of the meniscus with the proximal tibia
can be imaged only in the flexed stifle.
-With flexion, the insertion of the cranial cruciate onto the proximal tibia and the body of
the caudal cruciate can be imaged in a flexed stifle. To image the insertion of the cranial cruciate
ligament onto the proximal tibia, the stifle should be flexed and a medium to low frequency
sector; curved linear array, or matrix array transducer with a small footprint should be placed
between the medial and middle patellar ligaments distal to the patella. Then, the prob should be
angled toward the center of the femorotibial joint. From the caudal approach, the caudal
attachments of the menisci can be imaged from the caudal approach using low frequency
transducer, as are the cruciate ligaments.
-A small amount of anechoic fluid (less than 3 cm long) and little or no synovial villi are
usually imaged in the normal medial femorotibial joint, between the medial patellar ligament and
the medial collateral ligament.
-No synovial fluid is normally imaged in the subextensorius recess of the lateral
femorotibial joint.
-The articular cartilage over the lateral trochlear ridge is thicker (2-3 mm) than that over the
medial trochlear ridge (1-2 mm). To examine the entire articular margins of the femoral condyles,
the transducer should be held vertically and moved in a caudocranial direction. If the stifle is
examined in flexion, the cartilage and subchondral bone surface of the femoral condyles can be
imaged.
-The subchondral bone in the trochlear groove may appear irregular.
-The distal articular margins of the femoral condyles can be imaged in a flexed joint. The
caudal articular margins of the femoral condyles are visible with the caudal approach to the stifle
joint. The normal articular margins of the medial femoral condyle and tibial plateau are smooth
and regular.
-The size and content of the medial recess of the medial femorotibial joint are influenced by
all joint lesions.
-Diffuse injuries to the collateral ligaments of the femorotibial joint are common, with or
without the associated meniscal damage. (Fig. E-56, E-57)
Fig. E-56 A large area of bony proliferative change (arrows) at the origin of the lateral collateral ligament of the femorotibial joint in a horse
with chronic enthesopathy of the lateral aspect of the joint. This bony change is large and smooth consistent with a chronic problem
(Reef et al, 2004)
Fig. E-57: Left: Longitudinal ultrasound scan of desmitis in the medial collateral ligament of the femorotibial joint. This ligament is enlarged
and hypoechogenic (arrowheads). Transverse ultrasound scan of the ligament. 1, Skin; 2, Medial collateral ligament; 3, Medial
meniscus; 4, Medial femoral condyle (Deniox, 2003).
-In horses, injuries of medial meniscal (75%) occur more frequently than lateral meniscal
injuries (25%). Seven of 15 horses with meniscal injuries have an associated medial collateral
desmitis. The most frequent type of meniscal lesions found in horses is horizontal tears. Within
the injured meniscus, a mottled echogenicity and anechoic areas have been reported most
frequently. In horses with fibrosis and mineralization of the meniscus, hyperechoic areas within
the abnormal meniscus have been imaged (Fig. E-58, E-59). Abaxial bulging or prolapse of the
damaged meniscus is also common (Fig. E-60). Prolapse of the meniscus is easiest to document
when the horse is weight bearing. Collapse of the joint space may be seen in horses with meniscal
damage.
Fig. E-58 Medial aspect of the medial femorotibial joint showing a transverse section of the body of the medial meniscus. A hypochoic defect
(arrowheads) is seen. 1, Skin; 2, Medial collateral ligament; 3, Medial meniscus; 4, Medial femoral condyle (with anechoic articular
cartilage); 5, Medial tibial condyle (with anechoic articular cartilage) (Denoix, 2003).
Fig. E-59 A calcified medial meniscus obtained from a horse with stifle joint lameness. You can see the hyperechoic areas (arrows) with the
medial meniscus casting acoustic shadows, consistent with calcification. The edge of the meniscus is poorly defined but appears to be
prolapsing out of the joint space (Reef et al, 2004).
Fig. E-60 Above: Medial aspect of the medial femorotibial joint showing a transverse section of the cranial horn of the medial meniscus. A
hyperechogenic material is present in the deep part of the horn (arrowheads). Below: The diagnosis of the hyperechoic material is a
focal site of a mineralized metaplasia in a meniscus. 1, Skin; 2, Medial femoral fascia; 3, Medial meniscus; 3a, Cranial attachment; 4,
Medial femoral condyle; 5, Medial tibial condyle (Denoix, 2003)
-Injuries of cranial cruciate appear as anechoic to hypoechoic areas within the ligament or
fragmentation or complete disruption of the ligament. Bony changes and avulsion fractures
associated with the insertion of the cranial cruciate on the proximal tibia are detectable
ultrasonographically (Fig. E-61).
-Small to large cartilaginous and subchondral bony defects can be imaged in the lateral or
medial trochlear ridge of the femur. The ultrasonographic examination can detect small
subchondral bony defects and can provide information about the extent of the lesion (especially in
a medial to lateral direction), the size and location (attached or free floating) of any fragments, and
the extent of the underlying subchondral bone disease. The ultrasonographic examination can also
detect the osseous cyst-like lesions located in the medial and lateral femoral condyles. Thickened
hypoechoic cartilage with associated bony fragments has been imaged in horses with
osteochondrosis dessicans.
Fig. E-61 The cranial cruciate ligament in a horse with an avulsion fracture located at the insertion onto the proximal tibia (large arrow).
You can see the small hyperechoic echo casting an acoustic shadow that represents the avulsion fracture overlying the cranial
cruciate ligament at its insertion. A hypoechoic area lacking the normal parallel fiber pattern is imaged proximal to the avulsion
fracture in the cranial cruciate ligament (Reef et al, 2004).
-Abnormalities including synovial effusion (Fig. E-62), chronic proliferative synovitis,

hemarthrosis (Fig. E-63), echogenic spots combatible with fibrin, cartilaginous or meniscal debris
(Fig. E-64) and osteochondral fragments can be imajed ultrasonographically.
Fig. E-62. Distention in the medial recess of the medial femorotibial joint filled with anechogenic synovial fluid (synovitis). 1, Skin; 2, Medial
femoral fascia; 3, Synovial membrane; 4, Medial recess of the medial femorotibial joint; 5, Medial aspect of the distal femur (Denoix
2003).
Fig. E-63. The medial recess of the medial femorotibial joint. Echogenic material distends the recess and the diagnosis is hemarthrosis. 1,
Skin; 2, Medial femoral fascia; 3, Medial recess of the medial femorotibial joint; 4, Medial aspect of the distal femur (Denoix 2003).
Fig. E-64 The medial recess of the medial femorotibial joint. Echogenic material floats in the synovial fluid. The echogenic spots represents
fibrin, cartilaginous debris or meniscal debris. 1, Skin; 2, Medial femoral fascia; 3, Medial recess of the medial femorotibial joint; 4,
Medial femoral condyle; 5, Medial meniscus (anechogenic due to the orientation of the ultrasound beam (Denoix 2003).
Hock Joint
-In horses, the peroneous tertius, which is entirely tendinous structure extends from the
distal femur to the tarsus and branches to insert on the proximal aspect of third metatarsal bone,
the calcaneus, and the third and fourth tarsal bones. The ultrasonographic appearance of the
normal peroneus tertius shows a clearly defined homogeneous echogenic structure with a parallel
fiber pattern.
-The cranial tibial muscle that lies deep to the peroneus tertius inserts in two branches on
the proximal end of the metatarsal bone and on the first tarsal bone. The bifurcation of the tendon
occurs immediately distal to the bifurcation of the peroneus tertius tendon. There is a sheath
where the tendon takes its course superficially between the branches of insertion of the peroneus
tertius tendon and a bursa beneath the cunean tendon.
-The superficial digital flexor muscle lies between the two heads of the gastrocnemius
muscle. Its tendon is echogenic and has an oval shape, except at the point of the hock where it is
flattened when it has a crescent shape.
-The oval gastrocnemius tendon also flattens and becomes crescent-shaped as it inserts onto
the plantaroproximal aspect of the tuber calcis. Ultrasonographically, the gastrocnemius tendon
normally has some hypoechoic areas within the proximal to mid-portion of the crus, where it still
contains some residual muscle fibers and becomes more homogeneous in the distal crus. It is
necessary to examine the gastrocnemius tendon in the contralateral hindlimb and to determine
whether the hypoechoic areas imaged are associated with pathology, or they just reflect persistent
muscle fibers within the tendon.
-Dorsal to the insertion of the gastrocnemius tendon on the calcaneal tuberosity, the
gastrocnemius bursa is located.
-The calcaneal bursa is a large bursa lying deep to the SDFT, from the distal fourth of the
tibia to the middle of the tarsus. It is visible between the superficial digital flexor and the
gastrocnemius tendons.
-The collateral ligaments are multiple: one long and three short lateral and medial collateral
ligaments. The long lateral collateral ligament originates on the lateral malleolus of the tibia and
inserts on the distolateral calcaneus, fourth tarsal bone, third and fourth metatarsal bones. The
long medial collateral ligament originates on the medial malleolus of the tibia and extends distally
to its insertion on the distal tibial tuberosity of the tibial tarsal bone, the medial surface of the
small tarsal bones and the proximal portion of second and third metatarsal bones.
-The three short lateral collateral ligaments are partially fused at their origin on the lateral
malleolus of the tibia. The superficial short lateral collateral ligament inserts on the calcaneus and
tibial tarsal bone. The middle short lateral collateral ligament inserts on the tibial tarsal bone. The
deep short lateral collateral ligament inserts more dorsally on the tibial tarsal bone.
-Ultrasonographically, the medial and lateral collateral ligaments appear highly echogenic
fibrous structures.
-The three short medial collateral ligaments extend from the craniomedial aspect of the
medial malleolus of the tibia under the long collateral ligament to their insertions. The short flat
medial collateral ligament inserts on the proximal and distal tuberosity of the tibial tarsal bone;
part of that is immediately adjacent to the attachment of the long collateral ligament. The short
round medial collateral ligament inserts on the distomedial aspect of the sustentaculum tali and
the plantaromedial aspect of the central tarsal bone. The short flat deep collateral ligament inserts
on the tibial tarsal bone.
-The tarsal sheath (measures 20–30 cm) envelops the lateral digital flexor tendon and caudal
tibial tendon, two heads of the deep digital flexor tendon (DDFT), where it lies on the
sustentaculum tali (ST) of the calcaneus. Ultrasonic imaging of a normal sheath shows an
echogenic structure containing little fluid, and is generally not distinguishable from the DDFT
throughout its length.
-Over the dorsomedial compartment of the tarsocrual joint, the joint capsule can be imaged.
A large dorsomedial recess can be imaged just below the medial malleolus of the tibia. A little
anechoic synovial fluid can be imaged in the dorsomedial compartment of the tarsocrural joint
with distinct synovial villi floating within the fluid. In the normal plantaromedial or
plantarolateral compartments, little fluid is also imaged in the joint.
-In horses, normal thickness of the anechoic articular cartilage of the medial and lateral
trochlear ridge of the talus ranged between 0.5 and 0.9 mm and a similar thickness of the cartilage
over the distal intermediate ridge of the tibia.
-Minimal anechoic synovial fluid can be imaged in the medial aspect of the distal intertarsal
joint or in the plantarolateral aspect of the tarsometatarsal joint.
-In horses with tenosynovitis of the long digital extensor tendon sheath and of the tarsal
sheath, a hypoechoic fibrin and a thickened synovium are frequent findings.
-Lesions in the DDFT are commonly imaged in horses with septic tarsal sheath
tenosynovitis.
-Cunean bursitis or a bursitis of the tarsal tendon of the tibialis cranialis has been imaged
ultrasonographically.
-Gastrocnemius tendinitis is associated with an enlargement of its tendon proximal to the
point of the hock with a decrease in the tendon’s echogenicity and a disruption of its normal fiber
pattern (Fig. E-65).
Fig. E-65 Normal gastrocnemius tendon (right image) and left injured gastrocnemius tendon (left image). You can see the large hypoechoic
area in the dorsolateral aspect of the gastrocnemius tendon (large arrow) and the effusion in the calcaneal bursa (small arrow) (Reef
et al, 2004).
-Disruption of the attachment of the SDFT to the point of the hock can be imaged
ultrasonographically showing abnormal positioning and abnormal medial attachment of that
tendon.
-In case of desmitis of the plantar aspect of the hock or “curb”, hypoechoic core and diffuse
lesions and separation of fibre bundles, and an occasionally presence of calcifications have been
imaged within the plantar ligamen. Deep digital flexor tendinitis in the hock region may also
cause swelling that mimics a “curb.”
-In cases of haemarthrosis and septic synovitis, the synovial fluid appears hypo- to
echogenic. Fibrinous loculations, synovial thickening and hyperplasia may be present in septic,
non-septic, and eosinophilic synovitis (Fig. E-66)
Fig. E-66 Ultrasonographic images of the dorsal recess of the tarsocrural joint. The dorsal recess is filled with anechoic fluid (1) and the
synovial membrane (2) shows synovial proliferations (3). This horse had a non-septic synovitis. (4) Medical trochlear ridge of the
talus (Vanderperren et al, 2009).
-On ultrasound, the acute ruptured peroneus tertius appears enlarged and it shows multiple
small focal anechoic to hypoechoic lesions (Fig. E-67 A and B). On a longitudinal scan, the
normal fibre-orientation disappears. Ultrasonogra-phy has also been used to evaluate the healing
of a ruptured peroneus tertius.
Fig. E-67. (A) Ultrasonographic image at the dorsal aspect of the left tarsus of the peroneus tertius (PT). The PT is severely thickened and
shows a complete loss of fibre structure. (B) A normal image of PT of the right hindlimb of the same horse (Vanderperren et al,
2009).
-Tendonitis of the tibialis cranialis muscle, or its cunean branch, occurs and can be
ultrasonographically imaged. The ultrasonographic changes include disappearance of the normal
parallel fibre pattern. The cunean bursa may become distended with anechoic or echogenic fluid
associated with trauma or sepsis.
-Collateral desmitis appears to be less common here than in the stifle or fetlock joints. In
acute cases, the affected collateral ligament is usually enlarged, with a diffuse or discrete
hypoechoic area and disruption of a parallel fiber pattern ( Fig. E-68 A and B). In chronic lesions,
the injured collateral ligaments may remain thickened and may have focal echogenic sites
associated with mineralization. The enthesiophyte formation or avulsed fragments (Fig. E-69) at
the origin or insertion can also be identified with ultrasound. Ultrasonography facilitates the
differentiation between intra- and extra-articular avulsion fragments if radiography is
inconclusive.
Fig. E-68 (A) Ultrasonographic image performed at the lateral aspect of the right tarsus. The short part of the lateral collateral ligament
(short LCL, between +) is hypoechoic, thickened and shows a complete loss of fibre structure. (B) Normal image of the short part of
the lateral collateral ligament (between asterisks) of the left hindlimb. Talus: lateral aspect of the talus; long LCL: long part of the
lateral collateral ligament (Vanderperren et al, 2009).
Fig. E-69. Ultrasonographic image performed at the medial aspect of the tarsus. The short part of the medial collateral ligament (short
MCL) is enlarged and anechoic. A large hyperechogenic fragment (F), creating an acoustic shadow, is present at the distal aspect of
the medial malleolus. The long part of the medial collateral ligament (long MCL) is normal (Vanderperren et al, 2009).
-Ultrasonography of the tarsal sheath is the technique of choice for viewing and evaluating
the distension. Ultrasonographic distension of the tarsal sheath is presented as a swelling, visible
on both sides of the leg, in the groove between the Achilles tendon and the caudal tibia because
the tarsal sheath is only free to expand proximal to the tuber calcanei. Visible changes on
ultrasonographic images include synovial proliferation, intrathecal haemorrhage or adhesions or
masses, villonodular lesions, calcification within the tarsal sheath, herniation of the tarsal sheath,
enlargement of and/or hypoechoic areas, and mineralisation in the DDFT and the surface of the
ST (Fig. E-70). Mineralisation is a late complication of chronic disease, and can involve portions
of the mesotenon as well as the surface layers of the DDFT.
Fig. E-70. Ultrasonographic image of the plantaromedial aspect of the tarsus. You can see the mild distension of the tarsal sheath (TS) with
anechogenic fluid. DDFT: deep digital flexor tendon; FM: M. flexor digitalis medialis; SL: suspensory ligament; MT III: third
metatarsal bone (Vanderperren et al., 2009).
-Ultrasonographic evaluation of an acquired bursitis of the subcutaneous calcaneal bursa

‘capped hock’shows an accumulation of extensive bursal fluid and thickening of the bursal wall
by fibrous tissue (Fig. E-71 a).
Fig. E-71. (a) Ultrasonographic image of a subcutaneous calcaneal bursitis (capped hock) of the tarsus where the subcutaneous calcaneal
bursa (B) is filled with anechogenic fluid and some echoic material (arrow). The superficial digital flexor tendon (SDFT) is normal.
(b) Longitudinal (A) and transverse (B) ultrasonographic images of an intertendinous calcaneal bursitis. You can see the echogenic
fluid (isoechoic with the capsule) between the SDFT and the gastrocnemius tendon (GT); (C) calcaneus; intertendinous calcaneal
bursa (CB) (Vanderperren et al., 2009).
-Disorders of the intertendinous calcaneal bursa are rare. The ultrasound can be used to
diagnose the distension of the intertendinous calcaneal bursa. The bursa appears in the normal
horse as a thin anechoic line between the SDFT and the gastrocnemius tendon. Ultrasonographic
examination of an inflamed bursa results in an anechoic to hypoechoic effusion within it. Within
the synovial fluid, strands of echogenic material consistent with fibrin are usually detected (Fig.
E-71 b). Horses with a chronic bursitis have a thickening of the synovial lining and of the bursa
itself, and may show adhesions of the tendons within the bursa.
Chapter 9: Ultrasonography of Orthopedic (Non-Articular) Structures
Bone
Normal Ultrasonographic Appearance of Bone

-Ultrasonographically, a normal bone appears as a hyperechoic structure with a smooth
uniform thickness with an acoustic shadow from its near surface.
-In all extraarticular locations, a thin layer of hypoechoic soft tissue overlies the bone.
-Ultrasonographically, physis appears as a thin anechoic to hypoechoic line.
-At the site of the normal vascular channels penetrating the bone, small tubular breaks in the
normal bony surface echo are detected.
-The articular cartilage appears as a thin anechoic space overlying the hyperechoic
subchondral bone.
Abnormal Ultrasonographic Appearance of Bone
Fractures
-Ultrasonography is useful to diagnose fractures that cannot be detected radiographically
(e.g. the scapula, humerus, ribs, pelvis of horses) and to confirm the fracture of bone diagnosed
by radiograph. It is also useful to monitor fracture healing, looking for the formation of a bony
callus.
-For the determination whether a fracture is present, it is very helpful to compare between
the affected limb and the contralateral limb.
-The diagnosis of fractures depends on imaging the fracture line or fracture fragment in two
mutually perpendicular ultrasound planes. The detection of a distracted hyperechoic bony
structure in two mutually perpendicular planes is consistent with a displaced fracture fragment.
-A nondisplaced fracture is diagnosed when there is a break in the normal hyperechoic bony
surface echo.
Osteomylitis
-Ultrasonography is extremely useful in the detection of early osteomyelitis.
-The ultrasonic changes of osteomylitis appear as early as the fourth day (40% of patients)
(95% on the sixth day) after the onset of the infection (Radiographic detection after at least 10
days of the onset of the infection) .
-A fluid detected overlying the surgical implants or fracture fragments is highly suggestive
of osteomyelitis unless the ultrasound examination occurs immediately postoperation, or the fluid
overlying the bone is associated with an organizing hematoma from the fracture (Fig. E-72).
Fig. E-72 Left metacarpus of a horse with a surgical implant. You can see the fluid layer overlying the plate which appeared several weeks
after surgery, which indicates osteomyelitis and infection of the implant. (Reef et al, 2004).
-Lytic (appear as scooped out areas in the surface of the bone) and proliferative changes
(appears as hyperechoic spicules of bone) may also be seen ultrasonographically in the bone
underneath the superficial fluid layer (Fig. E-73).
Fig. E-73 The distal radius obtained from a horse with osteomyelitis. You can see the hypoechoic fluid layer overlying the bone (arrows) and
the irregularity of the underlying radius. (Reef et al, 2004)
.
-A sequestrum appears as a separate hyperechoic bony fragments slightly distracted from
the underlying bone in both short and long axis planes, surrounded by hypoechoic to anechoic
fluid (Fig. E-74).
-Cortical bone destruction, sequestrum formation, and subperiosteal abscesses have been
detected ultrasonographically and they are consistent with a diagnosis of osteomyelitis.
-It must differentiate between synovial fluid along the bone within a joint with the fluid
layer overlying bone in case of osteomyelitis.
-If there is fluid layer overlying bone, without any intervening soft tissue, in an animal with
clinical signs consistent with a diagnosis of osteomyelitis, the clinician should perform an
ultrasound- guided aspirate, or biopsy, of the area in question to obtain a sample for culture and
sensitivity testing, if surgical intervention is not indicated.
Fig. E-74 A sequestrum in the medial aspect of the mandible of a horse. You can see the hypoechoic fluid layer adjacent to the bone,
surrounding the distracted piece of bone (arrows) that is the sequestrum. These sonograms represent two mutually perpendicular
views of the sequestrum (Reef et al, 2004).
Incomplete Ossification of the Cuboidal Bones

-Ultrasonographic monitoring is useful for evaluating the incomplete ossification in young
animals.
-In horses, ossification grades 1 to 4 have been described by examining the tarsus. With
grade 1 ossification, no bony surfaces of the third or central tarsal bones is detected. Partial
ossification of the third and central tarsal bones is seen in grade 2 ossification, but these bones
may appear malaligned. A clearly visible ossification in the bony surfaces of the third and central
tarsal bones surrounded by thick cartilage is detected in grade 3. In grade 4, the bony surfaces of
the third and central tarsal bones are aligned, close to each other, and close to the skin surface.
-It has been shown that repeated sonographic monitoring of the tarsus is better tolerated in
these foals than repeated radiographic monitoring.
Foreign Bodies and Draining Tracts

-The tracts usually appear as hypoechoic linear paths containing various amounts of
anechoic to echoic fluid and/or gas depending on the composition.
-In case of puncture wound or draining tract, hyperechoic free gas echoes are usually seen
at the skin surface, and they decrease in number as the tract goes deeper, unless an anaerobic
infection is present.
-The tract of a puncture wound is usually detected for weeks after the healing of the skin
wound. It may image pockets of fluid within the tract, and usually surround the foreign body.
-The classic ultrasonographic appearance of a foreign body is an echoic to hyperechoic

structure surrounded by fluid.
-The most common foreign body detected in horses is wood which appears
ultrasonographically as a hyperechoic and casts a strong acoustic shadow from its near surface.
-Draining tracts should end at a foreign body, fracture fragment, sequestrum, bone
(osteomyelitis), or other necrotic tissue.
-All different types of foreign bodies or multiple foreign bodies can be detected
ultrasonographically. Some foreign bodies which are located in areas adjacent to vital structures,
such as vessels and nerves, could not have been successfully removed without ultrasonographic
guidance, both preoperatively and intraoperatively.
-The echogenicity of the reflector and the type of shadow or artifact created by the foreign
body suggest the type of foreign body present. A typical metallic reverberation artifact is
produced by a needle, nail, wire, and BB pellets. A strong echo from the near surface of the
foreign body and a strong acoustic shadow are usually produced by ood, glass, and gravel (Fig. E-
75). Graphite also produces a strong echo from the near surface of the foreign body, but produces
only moderate acoustic shadowing. Tubular hyperechoic structures that cast weak acoustic
shadows may represent a piece of hoof within the soft tissues associated with the drainage.
-The type of foreign body and the position of the ultrasound beam relative to the foreign
body determine the type of acoustic shadow cast by the foreign body. A necrotic tissue should be
considered as a cause of the drainage if a nonshadowing echoic or hyperechoic structure
surrounded by fluid is imaged, or the shadow arises from the far surface of the structure. An
abscess filled with cellular debris should be suspected if only low amplitude echoes are detected
without acoustic shadowing.
-Sonographic examination of a swelling or draining tract can be extremely useful in
localizing a foreign body in areas of inaccessible radiographically.
-Sonographic examination of the tongue and pharynx has been extremely useful in
identifying and localizing foreign bodies imbedded there.
Fig. E-75 The right cervical region of a horse with a wooden foreign body in the neck. You can see the large hyperechoic structure (small
arrows) casting a strong acoustic shadow consistent with wood, adjacent to the carotid artery (large arrow). (Reef et al, 2004).
Chapter 10: Muscles
Normal Ultrasonographic Appearance of Skeletal Muscle

-Ultrasonographically, normal skeletal muscle fibers appear as hypoechoic surrounded by
echoic fasia, connective tissue and fat.
-In short axis section, each individual normal muscle has a unique speckled appearance that
referes to its striated long axis appearance.
-An echoic line abetween the muscle bellies refers to the fascia.
-The comparison between contralateral muscles should be made when the horse is normally
weight bearing because a muscle appears more echoic when not bearing weight compared with
the same muscle with fully weight bearing. This may be as a result of more closely packed muscle
fasciculi.
Abnormal Ultrasonographic Findings of Skeletal Muscle
Muscle Injuries
-Ultrasonography can differentiate several types of muscle injuries from each other such as
muscle trauma, myositis or masses infiltrating the muscles.
-The most common lesion ultrscleonographically detected in muscle injuries is the areas of
muscle fiber disruption.
-A careful imaging of the affected muscles from their origin to insertion usually leads to
diagnose the lesions.
-Areas of acute muscle injury with hemorrhage appear as anechoic (fluid filled areas) with
hypoechoic loculations of muscle fiber tearing ( Fig. E-76, E-77 ).
Fig. E-76 Sonograms of the gracilis muscle with a large hematoma in a horse with an acute tear of the gracilis muscle with a large hematoma.
You can see the large amount of anechoic fluid and the hypoechoic to echoic strands of fibrin. The normal tissue of the gracilis
muscle can be seen (arrow). (Reef et al, 2004).
Fig. E-77 A gluteal muscle tear in a horse. You can see the small hypoechoic area within the center of the middle gluteal muscle (arrow).
(Reef et al, 2004)
-Ultrasonography is a useful technique for monitoring the resolution of the hematoma and
the repair of the muscle. Ultrasonographic imaging of muscle repairs show that the fluid becomes
more echoic and the area fills in with hypoechoic to echoic tissue. The healing scar tissue can be
detected as echoic areas of muscle associated with fibrotic myopathy, and are most frequently
imaged in horse in the semitendinosus and semimembranosus muscles.
- In horses with an ossifying myopathy, hyperechoic areas casting acoustic shadows are
imaged and are frequently found adjacent to areas of fibrotic myopathy. Near close to the
calcification areas, areas of acoustic shadowing can be seen as a result to the high acoustic
impedance of calcification relative to soft tissue.
Myopathy
-In a horse with suspected post anesthetic myopathy, the entire abnormal muscles should be
examined ultrasonographically.
-The more damage the muscle has the more severe the ultrasonographic changes.
-There is a positive correlation between the levels of creatine kinase (CK) with the severity
of the ultrasonographic changes.
-In case of post anesthetic myopathy, early lesion of muscle edema may appear as areas less
echoic than normal. With the increase of inflammatory cells, the affected muscle becomes more
echogenic with loss of the normal muscle striations.
-With necrotizing myositis, the affected muscle becomes more heterogeneous and often has
cavitation. In horses with an anaerobic necrotizing myositis, hyperechoic echoes associated with
the local production of gas by bacteria may be imaged (Fig. E-78)
-Ultrasonography is helpful in the diagnosis of deep abscesses within the muscle and in
locating a place to obtain an aspirate or a site for surgical drainage. In this case, disruption of the
normal muscle fiber pattern and replacement of the muscle tissue with hypoechoic to echoic fluid
is imaged. Loculations and hyperechoic echoes representing free gas may be imaged within the
abscess. A dorsal gas cap is often seen in large anaerobic abscesses.
Fig. E-78 An anaerobic myositis. You can see the large cavitation of the muscle (large arrows) and the small hyperechoic echoes within
representing gas within the necrotic muscle. (Reef et al, 2004).
Muscle Neoplasms
-Ultrasonographic biopsy and histopathological evaluation of the
tissue are important to accurately determine the type of a muscle mass.
-In general, muscle tumors are rare in animals, and muscle hemangiosarcoma represents the
most common muscle neoplasm in the horse.
-Ultrasonographic imaging of muscle hemangiosarcoma may show discrete echoic or
anechoic loculated more heterogeneous masses.
-Large or rapidly growing tumor masses show hypoechoic to anechoic areas in the center
which represents tumor necrosis.
-Some primary muscle tumors, such as rhabdomyosarcomas, appear as heterogeneous
masses that are totally disrupting the normal muscle architecture.
-In case of infiltrative lipoma, multiple hypoechoic areas surrounded by a thin layer of
tissue, that is isoechoic to the surrounding muscles, can be imaged.
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Subject Index
A Foreign Bodies, 113, 290
Fractures, 275, 288
Acoustic enhancement, 1, 19
Acoustic shadowing, 3, 18, 19, 101 G
Articular cartilage, 255, 264, 267
Artifact, 1 Ghost artifact, 18
Ascites, 69 Glaucoma, 233
B H
Back, 274 Heart, 30

Bacterial endocarditis, 32 Hepatic abscess, 80, 87
Bile ducts, 81 Hepatic fibrosis, 76, 79
Bone, 8, 15, 288 Hock Joint, 281
Hydrallantois, 165
C Hydrometra, 164, 165, 183, 184
Hydronephrosis, 99
Calcification of the bile duct, 81
Carpal Joint, 263 I
Caudal vena cava, 85
Cecum, 61 Ileus of the small intestine, 55
Cholangitis, and cholestasis, 82 Imaging Artifacts, 16
Coffin Joint, 272 Incomplete Ossification, 290
Comet Tail, 19, 20 Intestine, 54
Cornea, 229, 230 Iris/ciliary body, 231
Corpus luteum, 169, 189
Cystitis, 104 K
D Kidney, 15, 111, 152
Doppler ultrasound, 1, 13, 21, 220, 221 L

Double ovulation, 170
Lens, 232
E Lens subluxation, 232
LIGAMENTS, 237
Echocardiography, 24, 25, 30, 32, 33, 34, 35, 36, 111 Liver, 15, 73, 74, 111
Elbow Joint, 259
Embryo, 176, 196 M
Embryonic death, 130
Endometritis, 194 Mediastinal abscesses, 47
Eye, 225, 228, 295, 296 Mesothelioma, 66
Microphthalmos, 233
F Muscle Injuries, 292
Muscle Neoplasms, 294
Fat necrosis, 66 Myopathy, 293
Fatty liver disease, 76
Femorotibial Joints, 276 N
Fetlock Joint, 264
Flatulent colic, 63 Neck, 256
Follicle, 117, 118, 135, 139, 169, 192, 193
299
300 Subject Index
O S
Ossification, 147, 149, 152, 175 Shoulder Joint, 258

Osteomylitis, 288 Spasmodic colic, 65
Ovulation, 117, 188, 192, 196, 219 Stifle Joint, 275
Superior check ligament, 238
P Synovial Joint, 254
Synovial membrane, 255, 270, 280
Pancreas, 89
Pancreatic abscess, 94 T
Pancreatic biopsy, 90
Pancreatic fat necrosis, 93 Tendons, 237
Pancreatitis, 91 Tetralogy of Fallot, 31, 32
Pancreolithiasis, 92 Thrombosis, 86, 87, 111
Pelvis, 275 Torsion colic, 64
Pericarditis, 35, 111
Peritonitis, 71 U
Placentome, 144, 179, 180
Pleural abscesses, 46 Ultrasound waves, 14
Pleural Effusion, 42 Urinary bladder, 101, 116, 130
Pneumothorax, 43
Pregnancy, 140, 142, 175, 194, 220, 222 V
Pulmonary consolidation, 44
Pyelonephritis, 100 Ventricular septal defect, 31
Real-time Ultrasonography, 13
Refraction, 16, 18
Renal calculi, 101
Renal cysts, 99
Reticular abscesses, 53
Retrobulbar Masses, 235
Retroperitoneal abscessation, 68
Reverberation, 2, 16, 17
Ringdown, 20
Ahmed Mustafa H Ali Mohamed Tharwat Abdel-Al Fahd A. Al-Sobayil
Professor of Theriogenology Associate Professor of Veterinary Professor of Clinical

Internal Medicine and Laboratory Sciences
Diagnosis
Country Egypt Egypt Saudi Arabia
Suez - Egypt Sharkia - Egypt Unizah - Saudi Arabia

Birth
October 26th, 1963. October 12th, 1971. October 18th, 1968.
1994: BVSc (Fac.Vet. Med., Zagazig

1987: BVSc (Fac. Vet. Med., Assiut Univ., Univ., Egypt). 1992: BVSc (King Saud
Egypt). 1999: MVSc (Fac.Vet. Med., Zagazig University, Saudi Arabia).
Education 1992: MVSc (Faculty of Vet. Med., Assiut Univ., Egypt ). 1997: MVSc (Colorado State
Univ., Egypt). 2004: PhD (School of Veterinary University, USA).
2000: PhD (Clinic of Animal Reproduction, Medicine, Rakuno Gakuen University, 2003: PhD (Colorado State
FU-Berlin, Germany). Hokkaido, Japan). University, USA).
Associate Professor of Veterinary Internal

Professor of Theriogenology, College of Director of the Veterinary Teaching
Medicine and Laboratory Diagnosis,
Current Agriculture and Veterinary Medicine, Hospital, College of Agriculture
College of Agriculture and Veterinary
Position Qassim University. and Veterinary Medicine, Qassim
Medicine, Qassim University.
University.
Current: Current:
Department of Veterinary Medicine Department of Veterinary Medicine

College of Agriculture and Veterinary College of Agriculture and Veterinary Department of Veterinary Medicine
Medicine, Qassim University Medicine, Qassim University College of Agriculture and
Saudi Arabia Saudi Arabia Veterinary Medicine
Tel: +9660500960421 Qassim University
Address Email: mohamedtharwat129@gmail.com Buraydah 51452, P. O. Box 6622,
Al-Qassim
Permanent: Permanent: Saudi Arabia
Department of Theriogenology, Department of Animal Medicine Mobile: +96650398147
Faculty of Veterinary Medicine, Faculty of Veterinary Medicine Email: fsobayil@hotmail.com
Assiut University, Zagazig University
Egypt Egypt
Email: ahmedali77@hotmail.com Tel: +20552278348
301

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IN THE NAME OF ALLAH,

MOST GRACIOUS, MOST MERCIFUL

Farm Animal Ultrasonography

Ahmed Ali Mohamed Tharwat Fahd Al-Sobayil

King Fahd onal Library Cataloging-in-Publication Data

1- Traumatology 2- Trauma centers – Saudi Arabia

L.D. No. 1434/7656

“To my parents, my wife, and my children:Samia,

Part I: General physical principles of ultrasound 1

Part II: Ultrasonography and Veterinary Internal Medicine 23

Chapter 1: Ultrasonography of the Cardiovascular System 23

Ileus of the small intestine 55

Bladder content 105

Part III: Female and Male Reproductive Ultrasonography 113

Chapter I: Female Reproductive Tract Ultrasonography 113

I: Ultrasonography of the Male Reproductive Tract of the stallion 199

Part IV: Ultrasonography of the Eye and Musculoskeletal system

Chapter 6: The Back 274

General Physical Principles of Ultrasound

Fig. A-3: ultrasound generation.

Display of Images on Screen

Ultrasound is not emitted from the transducer continuously in B-mode diagnostic

Fig. A-5: Lateral and axial resolution (Goddard, 1995).

Watery Fluid Viscous Fluids Bone

Fig. 1-6: Interpretation the ultrasound gray shades

Fig. A-7: Piezoelectric material (www.sonochemistry.inf).

Linear transducers consist of a number (64-256) of such piezoelectric crystals precisely

Some transducers are capable of multifrequency operation. These transducers have

Fig. A-8: Focusing ultrasound wave (www.nextbigfuture.com).

Fig. A-9: Linear transducers

Mechanical sector probes consist of a small number of rotating transducer crystals,

Curve-linear probe is an electronic modified probe formsector one, which does

Doppler transducers in pulsed systems usually contain a

estimated by measuring the velocity with Doppler and

Modes of Echo Display

B-mode (brightness mode) displays the returning echoes

heart. M-mode tracings usually record depth on the vertical

Doppler ultrasound, often employed for studies of haemodynamics and pregnancy

Tissue–Ultrasound waves interaction

Attenuation of the Soundbeam

Table A-1: Ultrasound reflection at different interfaces

Fig. A-23: slice-thickness artifact, pseduosediment at the base of the bladder.

Acoustic enhancement (also called through-transmission) represents a localized

Fig. A-28: Acoustic enhancement distal to a mare ovarian follicle in estrus.

Fig. A-31: Ringdown artifact

10. Kahn W (2004). Veterinary Reproductive Ultrasonography. Schlutersche, Hannover, Germany.

Ultrasonography and Veterinary Internal Medicine

Mohamed Tharwat (BVSc, MVSc, PhD-Japan)

Chapter 1: Ultrasonography of the Cardiovascular System

 Recognition of specific structures and interpretation is based on a standardized imaging

Normal Echocardiographic Examination

A. Caudal long cardiac axis (right side)

a) Four chamber view

b) Left ventricular outflow tract (LVOT)

B. Caudal short axis view of the heart (right side)

C. Cranial long axis view of the heart (right side)

D. Caudal long axis view of the heart (left side)

a) Two chamber view

b) Left ventricular outflow tract

E. Cranial long axis view of the heart (left side)

Practical Application of Echocardiography

Congenital Heart Disease

Ventricular Septal Defect (VSD)

Acquired heart disease