Vet Clin Equine 21 (2005) 407–429

Equine Neonatal Thoracic

and Abdominal Ultrasonography
Michael B. Porter, DVM, PhDa,*,
Sammy Ramirez, DVM, MSb
a
Department of Large Animal Clinical Sciences, College of Veterinary Medicine,
University of Florida, 2015 SW 16th Avenue, PO Box 100136, Gainesville, FL 32610, USA
b
College of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA

Ultrasonography has become a well-established imaging modality in the

diagnostic workup of a wide variety of equine neonatal disorders. The small
size of neonates compared with adult horses makes foals ideal patients for
evaluation by this modality. Because ultrasonographic examination rarely
requires patient sedation, there are no contraindications for its use.
Improved image quality, availability, and cost of portable machines have
resulted in expanded use of this modality. The sonologist must have a good
understanding of the machine, equine anatomy, and indications and
limitations of ultrasonography to maximize its diagnostic potential,
however. This article is intended to serve as a review of ultrasound tech-
nique, normal anatomy, and some disease processes affecting the equine
neonatal thorax and abdomen.

General technique
As the name implies, ultrasound is characterized by high-frequency
sound waves that are inaudible to the human ear. Although ultrasound
frequencies can vary from 1 to 100 MHz, ultrasound waves commonly used
in diagnostic veterinary examinations produce sound waves with a frequency
range between 2 and 15 MHz.
Ultrasound machines generate sound waves in pulses by intermittently
energizing piezoelectric crystals within transducers (probes or scan head).
The same crystals then detect the returning echoes resulting from sound

* Corresponding author.
E-mail address: portermi@mail.vetmed.ufl.edu (M.B. Porter).

0749-0739/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.cveq.2005.05.001 vetequine.theclinics.com
408 PORTER & RAMIREZ

reflecting tissue interfaces. These returning echoes generate electrical

impulses that are electronically manipulated and displayed on ultrasound
machine monitors. Crystal thickness dictates the frequency of the trans-
ducer; thus, decreased crystal thickness produces shorter wavelengths and
higher frequencies. Frequency is inversely related to the depth of sound
beam penetration. Hence, low-frequency ultrasound waves (2–5 MHz) are
able to penetrate deeper distances compared with higher frequency ultra-
sound waves (10–15 MHz).
Most equine neonatal examinations can be performed with a transducer
frequency between 5 and 7.5 MHz. The highest frequency transducer
providing adequate penetration should be chosen to maximize resolution.
Newer multifrequency transducers have made clinical examinations easier
and faster because they allow multiple organs to be evaluated without
having to switch transducers.
Linear, curved (convex) linear, and sector transducers can be used. The
sector and curved linear transducers are preferred to a linear array
transducer because of the smaller contact area, allowing placement of the
transducer in the intercostal spaces and under the sternum. Additionally, the
wedge-shaped beam configuration of the sector and curved linear trans-
ducers allows deeper structures to be imaged and provides a wider field of
view than that of linear arrays.
The foal can be examined standing or in lateral recumbency. Hair
clipping of the ventral body wall from the xiphoid to the inguinal region and
one third to one half of the way up the lateral body wall is recommended for
optimum image resolution. Hair clipping may not be necessary if the hair
coat is thin, however. Because of the acoustic impedance between air and
soft tissue, the body wall should be moistened with aqueous ultrasound gel
or isopropyl alcohol to facilitate transmission of the ultrasound beam into
soft tissues.

Gastrointestinal tract
Normal structures
The stomach can be visualized from the left tenth intercostal space
approximately one half of the way up the lateral body wall and from the
ventral aspect of the cranial abdomen [1]. Its appearance varies depending
on its size and intraluminal contents, but it typically appears as a curvilinear
echo medial to the spleen and caudal to the liver (Fig. 1A). If it is filled with
gas, reverberation artifact and acoustic shadowing obscure deep portions of
the stomach. If it is filled with fluid, however, it is possible to examine
a larger portion of the stomach (see Fig. 1B). Gastric wall thickness in adult
horses can measure up to 7.5 mm and is usually thinner in foals [1]. The
duodenum can be visualized from the right side of the abdomen at
approximately the fifteenth intercostal space. It can be seen along the caudal
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 409

Fig. 1. (A) Sonogram of the left side of the abdomen in the tenth intercostal space obtained
from a normal neonatal foal. A portion of the fluid- and gas-filled stomach is seen cranial to the
spleen and deep to the intercostal musculature. The image was obtained with a 10-MHz linear
transducer and 6-cm displayed depth. (B) Sonogram of the left side of the abdomen in the tenth
intercostal space obtained from a neonatal foal with colic. A fluid-filled stomach is seen cranial
to the spleen and deep to the intercostal musculature. The spleen is displaced caudally because
of the overdistention of the stomach. The image was obtained with a 10-MHz linear transducer
and 7-cm displayed depth.

medial margins of the liver and followed caudodorsally around the caudal
pole of the right kidney. The ventral abdomen is usually occupied by the
large colon and small bowel. Because of the poorly developed large colon in
neonatal foals, sonographic evaluation of a large portion of the small
intestine is possible [1,2]. In foals older than 4 months of age, sonographic
visualization of the small intestine is limited to the inguinal region [3].
Sections of small bowel are viewed sagittally and transversely as the
transducer is moved from left to right and cranial to caudal. The depth of
field is set to visualize dorsally located bowel and is then decreased to
visualize superficially located bowel. The small intestine is generally flaccid,
characterized by little or transiently visible lumen contents [2,4], and usually
has rhythmic contractions (Fig. 2) [3]. Using a high-frequency transducer,
visualization of the hyperechoic mucosal surface, hypoechoic mucosa,
410 PORTER & RAMIREZ

Fig. 2. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. Several
loops of normal small intestine can be seen immediately adjacent to the body wall in cross
section. The image was obtained with a 10-MHz linear transducer and 4-cm displayed depth.

hyperechoic submucosa, hypoechoic muscularis propria, and hyperechoic

serosa is possible. In the ileum, an additional thin hyperechoic layer, which
represents connective tissue separating the longitudinal and circular
muscular layers, can also be seen [1]. Excluding the ileum, which is slightly
thicker (4–5 mm), the small and large bowel wall rarely exceeds 3 mm in
thickness [1]. It should be noted that large quantities of gas within the
gastrointestinal tract cause reverberation and shadowing artifacts, resulting
in difficulties in bowel wall measurement.
When evaluating the neonatal gastrointestinal tract, one should evaluate
bowel wall thickness and layering, uniformity in bowel diameter, luminal
contents, and peristalsis. If disease is present, one should determine whether
the disease is focal or generalized and which portion of the gastrointestinal
tract is affected. Because fluid-filled or edematous bowel gravitates toward
the dependent portion of the abdomen, it is imperative that the ventral-most
portion of the abdomen of a standing foal or the dependent side of
a laterally recumbent foal is closely evaluated [1,2].
Evaluation of the quantity and echogenic characteristics of peritoneal
fluid should be performed during examination of a neonatal abdomen.
Normally, there is a small amount of anechoic fluid visualized within the
abdomen. The ultrasonographic appearance of peritoneal effusion can vary
but typically becomes more echogenic as the cellularity increases (Fig. 3).
Visualization of gas echoes or particulate matter within the peritoneum is
indicative of a ruptured viscus. If abdominocentesis is warranted, the most
favorable site can be determined with the use of ultrasonography.

Abnormal structures
The ultrasonographic appearance of small intestine abnormalities,
including enteritis, intussusception, and mechanical obstruction, has been
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 411

Fig. 3. Sonogram of the caudal ventral abdomen obtained from a depressed neonatal foal
with colic. Several loops of small intestine in cross section can be seen suspended in anechoic
fluid. Cellular debris can be seen diffusely throughout the fluid. The image was obtained with a
2.4-MHz sector transducer and 15-cm displayed depth.

reported. The most common ultrasonographic abnormality associated with

enteritis is fluid-filled hypermotile bowel (Figs. 4 and 5) [1]. Hypomotile
bowel may also be seen, however [4]. The intestinal wall may be normal or
abnormally thickened, with normal wall layering. Multiple pinpoint gas
echoes within the bowel wall and shreds of sloughed mucosa within bowel
lumen, which appear as linear hyperechogenicities, may be seen in some
foals affected with clostridial enteritis [1,2].
Intussusception is a commonly recognized cause of colic in foals [5].
Although jejunojejunal intussusception is the most common intussusception
in foals, ileal-ileal, ileocecal, cecocolic, and cecocecal intussusceptions have
also been described [6]. Ultrasonographically, intussusceptions appear as

Fig. 4. Sonogram of the caudal ventral abdomen obtained from a depressed neonatal foal with
colic. Several loops of hypomotile small intestine in cross section can be seen suspended in
anechoic fluid. The intestinal wall appears thick, and the loops of intestine are distended. The
image was obtained with a 3.3-MHz sector transducer and 9-cm displayed depth.
412 PORTER & RAMIREZ

Fig. 5. Sonogram of the caudal ventral abdomen obtained from a depressed neonatal foal with
colic. Several loops of hypomotile small intestine in longitudinal section can be seen suspended
in anechoic fluid. The intestinal wall appears thick, and the loops of intestine are distended. The
image was obtained with a 3.3-MHz sector transducer and 9-cm displayed depth.

symmetric and multiple concentric rings representing wall layers of the

intussusceptum (inner bowel segment) and intussuscipiens (outer bowel
segment) (Fig. 6). The intussusceptum usually appears as a central echogenic
core representing normal bowel layering. Occasionally, invaginated
mesenteric fat, fluid, or fibrin may be present between the intussusceptum
and intussuscipiens. If the walls are compromised, they may appear
hypoechoic because of edema. In most cases, excess peritoneal effusion is
visible within the abdomen of foals affected with an intussusception [6].
With ileocecal intussusceptions, the sacculations of the outer segment of
bowel (cecum) may not be easily imaged [1]. Cecocolic intussusceptions may

Fig. 6. Sonogram of the caudal ventral abdomen obtained from a neonatal foal with diarrhea
and colic. Intussuscepted small intestines appear as multiple concentric rings (target lesions)
representing the inner and outer layers of the intussuscepted bowel. The intestinal wall appears
thick with edema and distended in cross section. The image was obtained with a 10-MHz sector
transducer and 6-cm displayed depth.
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 413

be differentiated from cecocecal intussusceptions by visualization of the

cecal tip of the intussuscepting cecum in cecocecal intussusceptions [6]. In
cecocolic intussusceptions, the cecal tip enters the right ventral colon and
may not be visualized [6]. Small intestinal intussusceptions may result in
partial or complete distention of bowel proximal to the lesion. Jejunojejunal
intussusceptions are usually imaged from the ventral abdomen, whereas
ileal-ileal, cecocolic, and cecocecal intussusceptions are usually seen from
the right flank and ventral abdominal region extending cranially toward the
sternum [6].
Ultrasonographically, a strangulated section of small intestine caused by
a hernia or congenital abnormality, such as Meckel’s diverticulum, appears
as turgid, fluid-filled, amotile or hypomotile small intestine (Fig. 7). The
small intestine proximal to the lesion is distended, whereas normal loops of
intestine are seen distal to the lesion. The affected intestinal wall is normal
shortly after the volvulus occurs; however, the wall becomes thickened from
congestion and edema, and the bowel distention becomes less noticeable as
the bowel undergoes ischemic necrosis (Fig. 8) [7]. With a complete volvulus,
the entire small intestine may be affected and congested mesenteric vessels
surround the mesenteric root [1]. The quantity of peritoneal fluid may be
increased, and fine linear echogenicities representing fibrin may be visualized
in strangulating obstructions. Because mechanical obstruction can appear
sonographically similar to enteritis, the sonographic findings should always
be interpreted in conjunction with the physical examination findings,
history, laboratory data, and abdominocentesis results. At times, the
diagnosis may still be unclear despite the physical examination findings,
history, laboratory data, and abdominocentesis results, and follow-up
ultrasound may be warranted.

Fig. 7. Sonogram of the ventral abdomen obtained from a depressed neonatal foal with colic. A
single loop of hypomotile small intestine in cross section can be seen. The intestinal wall is thick,
and the loop of intestine is distended. The image was obtained with a 10-MHz sector transducer
and 4-cm displayed depth.
414 PORTER & RAMIREZ

Fig. 8. Sonogram of the caudal ventral abdomen obtained from a refluxing neonatal foal.
Several loops of hypomotile small intestine in cross section can be seen suspended in anechoic
fluid. The intestinal wall appears thick, and the loops of intestine are distended. An adhesion is
seen between the body wall and a loop of small intestine (arrow). The image was obtained with
a 10-MHz sector transducer and 7-cm displayed depth.

Small intestinal adhesions and excessive peritoneal effusion may be seen

in some foals with small intestinal volvulus, enteritis, intussusceptions, or
viscus rupture (see Fig. 8). To identify adhesions, the transducer should be
held still in one position while observing whether the intestines move
independently between one another, adjacent organs, or peritoneum. Loops
of bowel that are fixed in position, especially after abdominal surgery,
suggest adhesions [3].
By far, one of the most common clinical complaints in equine neonates
associated with colic is meconium impaction. Careful examination of the
entire abdomen with an ultrasound transducer may provide information
regarding the extent and severity of the impaction (Fig. 9).

Fig. 9. Sonogram of the cranial ventral abdomen obtained from a newborn foal with colic. A
hypoechoic structure that casts an acoustic shadow is noted within the lumen of the large colon,
consistent with meconium impaction. The image was obtained with a 10-MHz sector transducer
and 7-cm displayed depth.
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 415

Urogenital tract
Normal structures
In foals less than 4 weeks of age, the urinary bladder and umbilical
remnants are located in the caudal ventral abdomen and easily examined
sonographically. Between 4 and 8 weeks of age, these structures regress
toward the pelvic brim and become difficult to visualize, especially when
obscured by gas within the large colon [1]. The urinary bladder is visualized
as an anechoic oblong structure with a thin echogenic wall (Fig. 10). At
times, large blood clots caused by trauma during birth may be seen within
the urinary bladder [3]. Because urinary bladder wall thickness varies with
the degree of distention, the urinary bladder is best examined when
moderately full. Ultrasonography has become the primary modality for
evaluation of the umbilicus [1,2,8,9]. The umbilicus is formed by paired
umbilical arteries, an umbilical vein, and the urachus and can be divided
into external and internal parts. As the umbilicus atrophies, the external
portion detaches from the skin, whereas the internal portion becomes
normal ligaments that regress into the abdomen. The arteries become the
left and right round ligaments of the urinary bladder, and the umbilical vein
becomes the falciform ligament.

Abnormal structures
A diagnosis of uroperitoneum secondary to urinary bladder rupture may
be easily and quickly assessed with the aid of ultrasonography. Typically,
a ruptured urinary bladder is collapsed and floating within an anechoic
peritoneal effusion. Urinary bladders with small tears can appear full and

Fig. 10. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
urinary bladder appears as an irregularly shaped structure that is filled with anechoic fluid. A
hyperechoic structure is seen protruding ventrally into the bladder, most likely consistent with
a postfoaling blood clot. The image was obtained with a 10-MHz linear transducer and 4-cm
displayed depth.
416 PORTER & RAMIREZ

turgid, however [2]. The tear commonly occurs in the dorsal urinary bladder
wall. The defect may not always be imaged during the sonographic
examination because of infolding of the bladder wall. The infolding wall
should not be mistaken for a recently voided small and contracted urinary
bladder. During real-time examination, urine may be seen passing through
the rent and into the peritoneum. Anechoic fluid is typically seen within the
abdominal cavity in foals with uroperitoneum. Some foals may have
echogenic fluid from peritonitis or urinary sediment, however [1]. In acute
cases, the quantity of fluid within the peritoneum may be small. Therefore,
the most dependent portion of the abdomen should be carefully evaluated [2].
Abnormalities associated with the external umbilical stump include
infections, hernias, and a patent urachus. Pain, heat, discharge, and swelling
of the external umbilicus can be seen on physical examination and may be
indicative of an infection. Ultrasound helps to determine whether the
swelling is associated with the vein, arteries, or urachus and differentiates
whether edema, fibrosis, or intraluminal fluid is affecting these structures. In
some foals with small defects in the body wall, leakage of peritoneal fluid
can cause warm soft tissue swelling in the region of the umbilicus. In these
cases, ultrasonography helps to differentiate between cellulitis and the
dissection of peritoneal fluid into the subcutaneous tissues [2]. A hernia may
be diagnosed with digital palpation alone; however, ultrasonography allows
evaluation of the herniated contents (ie, omental fat, bowel) and, if bowel is
present, the viability of its wall [2]. A moist external umbilicus consistent
with a patent urachus may be seen on physical examination. Ultrasonog-
raphy allows evaluation of the entire size and character of the urachus and
periurachal tissues, however, assisting in differentiating between a simple
patent urachus and an internal or external infectious process.
Evaluation of the internal umbilical remnants has been well described.
The umbilical vein, which eventually forms the falciform ligament of the
liver, is present on midline approximately 1 to 2 cm deep to the skin surface
and extends cranially from the external umbilical stump to the liver
(Fig. 11). Sonographically, it appears as a thin-walled ovoid structure with
an anechoic center that measures from 0.5 to 1.0 cm in diameter [1]. The
sections next to the liver and external umbilical stump are usually the largest
in diameter [1]. The vein is easier to follow while orienting the transducer
perpendicular to the spine. Transverse and sagittal measurements should be
obtained. Normally, the transverse diameter is slightly larger than the
sagittal diameter [1].
The umbilical arteries originate from the internal iliac arteries and
descend ventrally along the urinary bladder, coursing past the apex toward
the umbilicus along the urachus. Sonographically, they appear as thick-
walled hyperechoic vessels that normally measure less than 1.3 cm in
diameter (Figs. 12–16) [1]. They may be asymmetric in size, may be seen
pulsating in foals less than 24 hours of age, and may contain an echogenic
center if filled with clotted blood [1].
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 417

Fig. 11. (A) Sonogram of the cranial ventral abdomen obtained from a normal neonatal foal.
The umbilical vein (UV) is seen adjacent to the liver and deep to the abdominal wall. The image
was obtained with a 10-MHz linear transducer and 4-cm displayed depth. (B) Sonogram of the
cranial ventral abdomen obtained from a neonatal foal with a persistent fever. The UV is seen in
cross section and appears distended with hyperechoic material, consistent with abscessation of
the vessel. The image was obtained with a 10-MHz linear transducer and 4-cm displayed depth.

The urachus extends from the external stump to the apex of the urinary
bladder. It is a long tubular structure with a collapsed center that is nor-
mally difficult to view sonographically unless it is fluid-filled. Its communi-
cation with the apex of the urinary bladder is best seen with a sagittal view.
At the apex of the bladder, a transverse view of the urachus and arteries
normally measures less than 2.5 cm in diameter [1].
Infection is a common abnormality affecting the internal umbilical
remnants. Intraluminal distention with fluid and thickening of surrounding
tissue of any or all umbilical remnants is consistent with an infectious
process. The echogenicity of the intraluminal fluid can be hypoechoic,
anechoic, or echogenic (Fig. 17) [1,2,8]. The presence of small gas echoes
may be indicative of anaerobic infection. An urachal infection may ascend
proximally and result in concurrent cystitis in some foals [1]. Additionally,
some foals with urachal infections may develop localized adhesions to the
418 PORTER & RAMIREZ

Fig. 12. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
ultrasound transducer is located immediately caudal to the external umbilical stump and
perpendicular to the midline. The pair of umbilical arteries can be seen in cross section just deep
to the body wall. The image was obtained with a 10-MHz linear transducer and 4-cm displayed
depth.

adjacent gastrointestinal tract and spleen [1]. Thus, the surrounding tissues
should be evaluated in all foals with colic and infected umbilical remnants.
It should be noted that intraluminal fluid secondary to an infectious process
could be indistinguishable from hemorrhage secondary to trauma during
foaling (Fig. 18). For this reason, the ultrasonographic abnormalities should
be correlated with the history, clinical signs, physical examination findings,
and clinical laboratory data.

Fig. 13. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
ultrasound transducer is located slightly caudal to that in Fig. 12 and perpendicular to the
midline. The pair of umbilical arteries can be seen in cross section, and the urachus is noted
centered between the arteries. The image was obtained with a 10-MHz linear transducer and
4-cm displayed depth.
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 419

Fig. 14. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
ultrasound transducer is located slightly caudal to that in Fig. 13 and perpendicular to the
midline. The pair of umbilical arteries can be seen in cross section moving further apart, and
the tip of the urinary bladder is centered between the arteries. The image was obtained with
a 10-MHz linear transducer and 4-cm displayed depth.

Renal
Normal structures
The right kidney is located high in the fourteenth to sixteenth intercostal
space just ventral to the transverse processes and close to the lateral
abdominal wall (Fig. 19) [1,8]. The left kidney is more variable in location
but is commonly located in the seventeenth intercostal space or paralumbar
fossa medial to the spleen and is more ventrally located than the right
kidney (Fig. 20). Occasionally, it may be seen adjacent to the body wall.

Fig. 15. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
ultrasound transducer is located slightly caudal to that in Fig. 14 and perpendicular to the
midline. The pair of umbilical arteries can be seen in cross section, and a greater portion of
the urinary bladder is visualized. The image was obtained with a 10-MHz linear transducer and
4-cm displayed depth.
420 PORTER & RAMIREZ

Fig. 16. Sonogram of the caudal ventral abdomen obtained from a normal neonatal foal. The
ultrasound transducer is located slightly caudal to that in Fig. 15 and perpendicular to the
midline. The pair of umbilical arteries can be seen in cross section on either side of the urinary
bladder. The image was obtained with a 10-MHz linear transducer and 4-cm displayed depth.

Within the renal parenchyma, the renal medulla that contains the fluid-filled
tubules is less echogenic than the cortex. The renal cortex is less echogenic
than the liver and spleen. The normal ureters are not visible with
ultrasonography [2].

Abnormal structures
Some renal abnormalities reported in foals include acute renal failure,
embolic nephritis, and hydronephrosis [1,10]. Ultrasonography of a foal

Fig. 17. Sonogram of the caudal ventral abdomen obtained from a neonatal foal with
a persistent fever. The ultrasound transducer is located slightly caudal to the external umbilicus
and perpendicular to the midline. The umbilical arteries are poorly visible because of the
hyperechoic structure located in the center of the internal umbilicus. The variation in
echogenicity and increased diameter are consistent with abscessation of the internal umbilicus.
The image was obtained with a 10-MHz linear transducer and 4-cm displayed depth.
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 421

Fig. 18. Sonogram of the caudal ventral abdomen obtained from a normal 24-hour-old foal.
The ultrasound transducer is located slightly caudal to the external umbilicus and perpendicular
to the midline. The umbilical structures are poorly visible because of the apparent hematoma
formation around both umbilical arteries. The image was obtained with a 10-MHz linear
transducer and 5-cm displayed depth.

with acute renal failure may reveal no sonographic abnormalities, but some
foals may have renomegaly, hypoechoic kidneys, and perirenal edema.
Embolic nephritis, which has been reported in colostrum-deficient foals,
may present as diffuse or multifocal parenchymal echogenicities [1,10].
Hydronephrosis typically occurs with urinary tract obstruction but has also
been reported in one foal with ectopic ureters [1,11]. It should be noted that
mild hydronephrosis might be seen in animals undergoing intravenous fluid
administration [1,12].

Fig. 19. Sonogram of the right side of the abdomen within the sixteenth intercostal space and
just ventral to the transverse processes obtained from a normal neonatal foal. The right kidney
is visualized in the long axis. The image was obtained with a 3.3-MHz sector transducer and
10-cm displayed depth.
422 PORTER & RAMIREZ

Fig. 20. Sonogram of the left side of the abdomen within the seventeenth intercostal space
and cranial to the paralumbar fossa obtained from a normal neonatal foal. The left kidney is
visualized in the partial long axis. The left kidney is immediately adjacent to the spleen
and appears less echogenic when compared with the spleen. The image was obtained with a
3.3-MHz sector transducer and 11-cm displayed depth.

Hepatic
Normal structures
The liver can be seen from the right and left sides of the abdomen;
however, a larger portion can be seen from the right side [1,8]. It can be seen
ventral to the lung margins between the sixth and fifteenth intercostal spaces
on the right and between the sixth and ninth intercostal spaces on the left.
In foals less than 8 weeks of age, the cranial ventral portion of the liver is
in contact with the abdomen and therefore can be imaged just caudal to
the xiphoid. Normally, the hepatic parenchyma is uniformly of medium
echogenicity (ie, hyperechoic to the kidneys, hypoechoic to the spleen),
with the hepatic and portal veins interrupting the uniform echo pattern
(Fig. 21). The biliary tracts and hepatic arteries are not normally visualized
unless abnormal. The portal vasculature has echogenic walls and therefore
can be differentiated from the hepatic veins, which lack echogenic walls.
Because biliary tracts contain echogenic walls, Doppler ultrasonography is
needed to differentiate abnormally dilated biliary tracts from portal veins.

Abnormal structures
Although determination of liver size is usually based on subjective
assessment, it has been reported that approximately 4 to 8 cm of liver is
visible from the lateral body wall [1]. Multiple factors, however, including
size of the thoracic cavity and colonic distention, can influence the quantity
of liver visualized in this manner. Subjectively, hepatomegaly should be
suspected when there is rounding of the liver margins and an increased
distance between the stomach and diaphragm and when liver margins
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 423

Fig. 21. Sonogram of the left side of the cranial ventral abdomen obtained from a normal
neonatal foal. The spleen and liver are adjacent to each other, and the difference in echogenicity
is apparent. The normal spleen is hyperechogenic compared with the normal liver. The image
was obtained with a 10-MHz linear transducer and 6-cm displayed depth.

extend beyond the rib cage [13]. Conversely, a small liver should be
suspected when there is a decreased distance between the stomach and
diaphragm and poor visualization of the liver in the absence of pulmonary
hyperinflation and gas within the stomach.
Suppurative hepatitis and cholangiohepatitis have been reported in foals.
Bacterial infections of the liver, including Bacillus piriformis and Actino-
bacillus, occur in foals. A previous report of a foal diagnosed with acute
hepatic disorder attributed to Tyzzer’s disease revealed hepatomegaly and
an increased vascular pattern noted on ultrasound examination [14]. A
hypoechoic liver and collapse of the hepatic parenchyma may be seen in
foals diagnosed with toxic hepatopathy or hepatocellular necrosis [1].
Cholangiohepatitis secondary to biliary reflux attributable to duodenitis or
duodenal stricture may reveal thickened and distended biliary tracts and
hyperechoic hepatic parenchyma [1].

Spleen
Normal structures
The spleen is the most echogenic organ within the abdomen. The
parenchyma is primarily homogeneous, except for a few vessels derived
from the splenic artery and vein. An echogenic capsule surrounds the spleen
(see Figs. 1A and 21) [13]. The splenic vein is located medial to the spleen
and is present around the 10 intercostal spaces [1]. The spleen is variable in
location depending on gastric distention and the size of adjacent organs,
such as the liver. Normally, it is seen from approximately the left sixth
intercostal space to the paralumbar fossa. It is usually located lateral,
caudal, and ventral to the left kidney and medial to the left lobe of the liver.
It is variable in size and must be assessed subjectively.
424 PORTER & RAMIREZ

Abnormal structures
When enlarged, it may extend caudally to the urinary bladder and cross
midline. Although, splenic diseases are uncommon in foals, a hematoma
from blunt trauma to the abdomen caused by a kick may occur [1]. A
hematoma and a variable quantity of intra-abdominal hemorrhage may be
seen. The hematoma may be within the parenchyma or subcapsular. Its ul-
trasound appearance may vary depending on its age. Initially, the hema-
toma may appear hyperechoic but gradually becomes hypoechoic over time.

Pulmonary
Scanning technique
It is typically not necessary to clip the thorax free of hair. Alternatively,
rubbing alcohol can be used as a medium for generating adequate contact
and providing a diagnostic image. Because of rapid evaporation, the alcohol
is only applied immediately before placement of the ultrasound probe.
Transthoracic ultrasound in equine neonates can be performed with
ultrasound transducers ranging from 5.0 to 10.0 MHz and a depth setting
of 5 to 10 cm. Thus, a 7.5-MHz transducer that is used for transrectal
ultrasound is adequate in most cases. The author prefers to begin scanning
at the dorsal-caudal border of the lung field located in the sixteenth
intercostal space and level with the tuber coxae. The lung can be imaged
from the right and left sides within the sixteenth to fourth intercostal spaces.
In addition, the right apical lung lobe and cranial mediastinum can be
imaged in the right third intercostal space by advancing the foal’s right
foreleg forward and pointing the transducer toward the point of the left
shoulder [1,15,16]. Regardless of the type of ultrasound probe (sector versus
linear), the probe orientation should not change from one intercostal space
to the next. The operator should always scan in a dorsal-to-ventral direction
through each intercostal space until visualizing the diaphragm and ab-
dominal structures ventral to the diaphragm. In addition to documenting
any abnormalities in the pulmonary tissues, as the operator scans each
intercostal space, he or she should monitor for musculoskeletal prob-
lems, such as fractured ribs. These appear as ‘‘steps’’ producing acoustic
shadowing (Fig. 22).

Normal structures
The normal visceral pleural surface of the lung appears as a straight
hyperechoic line with equally spaced artifacts deep to the pleural surface
(Fig. 23). These artifacts are attributable to the almost 100% reflection of
ultrasound waves by the air– or gas–soft tissue interface. Therefore, if the
lung is inflated or aerated, the image only yields information regarding the
pleural surface of the lung. In the normal patient, the hyperechoic line
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 425

Fig. 22. Sonogram of the left side of the ventral thorax along the fifth rib obtained from
a neonatal foal with neonatal maladjustment syndrome. The ultrasound transducer is
positioned parallel to the rib, and a ‘‘step’’ is detected at the site of the fracture. A pocket of
anechoic fluid is noted around the fracture site, most likely consistent with a hematoma. The
image was obtained with a 10-MHz linear transducer and 4-cm displayed depth.

representing the pleural surface should be continuous with no aberrations

(ie, comet tails) (Fig. 24). In addition, ‘‘the gliding sign’’ or back-and-forth
movements of the pleural surface synchronous with respiration should be
observed in normal patients with the transducer held motionless [1,16]. It is
not normal to detect pleural fluid; however, a small volume of anechoic fluid
may be considered normal just caudal to the heart in the most ventral
portion of the thorax. Furthermore, the thymus may be visualized in the
equine neonate from the right third intercostal space as a hypoechoic soft
tissue mass located in the cranial mediastinum.

Fig. 23. Sonogram of the left side of the middle thorax along the sixth intercostal space
obtained from a normal neonatal foal. The ultrasound transducer is located within the
intercostal space and is parallel with the rib. The pleural surface appears as a hyperechoic line.
The image was obtained with a 10-MHz linear transducer and 7-cm displayed depth.
426 PORTER & RAMIREZ

Fig. 24. Sonogram of the left side of the middle thorax along the sixth intercostal space
obtained from a neonatal foal with mild pneumonia. The ultrasound transducer is located
within the intercostal space and is parallel with the rib. The pleural surface appears as
a hyperechoic line that is interrupted by ‘‘comet tails.’’ These disruptions in the normal pleural
surface correspond with thickening of the pleura. The image was obtained with a 10-MHz linear
transducer and 6-cm displayed depth.

Abnormal structures
Pathologic conditions diagnosed by ultrasonography include pleuro-
pneumonia, superficial pulmonary abscess, pulmonary consolidation,
pneumothorax, and fractured ribs. The ultrasonographic appearance of
pleural fluid in an equine neonate, although rare, is similar to that seen in
adult horses. An area of anechoic space representing fluid is noted between
the lung and the thoracic wall, diaphragm, or heart, depending on its
location (Fig. 25). In adults, the presence of pleural fluid is commonly
associated with infectious diseases of the lung. Additional differentials for
pleural fluid in equine neonates include penetrating thoracic wounds,
congenital abnormalities, hemothorax, and uroperitoneum resulting in the
diffusion of urine from the abdomen into the pleural space. If pleural fluid is
detected, it should be studied carefully to determine the presence of fibrin,
cellular debris, and free gas. Thoracocentesis is required to assess the fluid
accurately and should be performed where the largest pocket of loculated
fluid is imaged with care to avoid causing trauma to the heart, diaphragm,
or lung tissue. Ultrasonography can be used to monitor progress after
pleural fluid drainage.
Consolidation of lung tissue or pulmonary parenchymal consolidation
refers to the filling of alveolar tissue with fluid rather than air and can
represent bronchopneumonia, pleural pneumonia, pulmonary edema,
pulmonary necrosis, or neoplasia. Ultrasonographically, consolidated lung
tissue is commonly wedge shaped, with areas of echogenicity ranging from
anechoic to hyperechoic (Fig. 26) [1,16]. Lung tissue consolidation results in
ultrasonographic visualization of normally unseen lung anatomy, including
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 427

Fig. 25. Sonogram of the left side of the cranial ventral thorax along the fourth intercostal
space obtained from a normal neonatal foal. The ultrasound transducer is located within the
intercostal space and is parallel with the rib. A small amount of anechoic fluid is present in the
cranial ventral aspect of the thorax immediately caudal to the heart. The image was obtained
with a 10-MHz linear transducer and 6-cm displayed depth.

pulmonary vessels, air bronchograms, and fluid bronchograms [1,17]. In the

most severe cases of lung consolidation, the tissue appears ultrasono-
graphically similar to hepatic tissue and the branching pattern of fluid-filled
bronchi (fluid bronchograms) can be noted. Sonographic air bronchograms
appear as hyperechoic branching linear echoes within consolidated tissue
and correspond to the interface between air-filled bronchi and consolidated
pulmonary parenchyma [18]. Occasionally, multifocal hyperechoic gas
echoes are detected in consolidated pulmonary parenchyma, indicating the

Fig. 26. Sonogram of the right side of the caudal ventral thorax along the seventh intercostal
space obtained from a neonatal foal with severe aspiration pneumonia. The ultrasound
transducer is located within the intercostal space and is parallel with the rib. The lung lobe
appears as hepatic tissue because it is consolidated and suspended in anechoic fluid. The image
was obtained with a 5.0-MHz sector transducer and 10-cm displayed depth.
428 PORTER & RAMIREZ

presence of anaerobic bacteria. Ultrasonographic evidence of consolidation

is often preceded by the development of comet tails that correspond to the
accumulation of small amounts of exudate or cellular debris at the lung
surface. Likewise, the resolution of consolidation is commonly associated
with the appearance of comet tails in areas that were once without air (see
Fig. 24). Meconium aspiration and sepsis are common causes of pulmonary
parenchymal consolidation in equine neonates. In older foals, lung con-
solidation and pleural pulmonary abscesses are common findings in foals
infected with Rhodococcus equi.
In contrast to pulmonary consolidation, a pulmonary abscess lacks any
normal pulmonary architecture and appears as a cavitated lesion with an
anechoic center and acoustic enhancement of the far wall indicative of
a fluid-filled structure (Fig. 27) [1,8,16]. Pulmonary abscesses are not
common in newborn foals; however, severe aspiration pneumonia may
result in the development of an abscess. In addition, a pulmonary hematoma
secondary to trauma during foaling may appear ultrasonographically as
a fluid-filled structure. It is important to note that the absence of pulmonary
abscesses on ultrasound examination does not preclude their existence;
hence, radiographic evaluation of the thorax is required to evaluate the lung
field fully.
A pneumothorax is difficult to detect via ultrasound, because the free gas
within the pleural space and the air within the lung generate similar
hyperechoic reflection and reverberation artifacts. Careful examination
should reveal the absence of the gliding sign at the site of the pneumothorax,
however, because the pneumothorax is hiding the respiratory excursions of
the lung surface [1,8]. The detection of a pneumothorax in an equine
neonate suggests the presence of a penetrating thoracic wound, such as

Fig. 27. Sonogram of the right side of the middle thorax along the fifth intercostal space
obtained from a neonatal foal with severe aspiration pneumonia. The ultrasound transducer is
located within the intercostal space and is parallel with the rib. The pulmonary abscess appears
as a cavitated lesion with varying echogenicity. The image was obtained with a 10-MHz sector
transducer and 6-cm displayed depth.
 THORACIC AND ABDOMINAL ULTRASONOGRAPHY 429

a fractured rib. Although rib fractures are relatively common in newborn

foals, the incidence of pneumothorax associated with this condition is low.

Summary
Pathologic disorders of the equine neonate often develop shortly after
foaling as a result of prematurity, dystocia, trauma, or septicemia.
Recognition of these disorders requires routine patient assessment along
with diagnostic aids, including abdominal and thoracic ultrasonography.
Fortunately, modern technology affords today’s equine practitioners the
opportunity to use ultrasonography to advance their practice, and it is the
authors’ hope that this article might help in those efforts.

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