ADVANCED

IMAGING
OF EXOTIC
COMPANION
MAMMALS
SATURDAY, AUGUST 9, 2008
HYATT REGENCY HOTEL
SAVANNAH, GEORGIA

Special Thanks to
EKLIN, ALOKA & VETRONICS

Animals Provided by:

Jed Ball and Holly Tomlin (Ferrets)
House Rabbit Society - North Georgia
Chapter (Rabbits)
Steele Creek Cavy Corner (Guinea Pigs)
 Diagnostic Imaging of Exotic Companion Mammals
Association of Exotic Mammal Veterinarians August 9, 2008

Instructors:
Vittorio Capelloa, Angela Lennoxb, Natalie Antinoffc, Michelle Fabianid, Cathy Johnson-Delaneye

Schedule Morning Lecture Presentations

8:00 am Welcome and announcements
8:10 am Introduction to Anatomy (Natalie Antinoff)
8:40 am Sedation and Anesthesia for Radiology and Ultrasonography (Angela Lennox)
9:10 am Getting Great Radiographs in Exotic Companion Mammals (Vittorio Capello)
9:40 am Ultrasonography (Michelle Fabiani)
10:00 - 10:20 am Break
10:20 am Ultrasonography – continued (Michelle Fabiani)
11:20 am Introduction to Computed Tomography (Vittorio Capello)
12:00 pm End of the session.

Schedule Afternoon Wet Lab

2 sections, at break, switch
1:30 - 3:30 pm Radiology: Group 1 (Capello, Lennox), Ultrasonography (Antinoff, Fabiani,
Johnson-Delaney) Group 2
3:30 - 3:45 pm Break
3:45 - 5:45 pm Radiology Group 2, Ultrasonography Group 1

a. Clinica Veterinaria S.Siro; Clinica Veterinaria Gran Sasso; Milano, Italy

b. Avian and Exotic Animal Clinic of Indianapolis 9330 Waldemar Rd. Indianapolis IN 46268
c. Gulf Coast Avian & Exotics, 1111 West Loop South, Houston, TX 77027
d. Gulf Coast Diagnostic Imaging, 1111 West Loop South, Houston, TX 77027
e. Eastside Avian & Exotic Animal Medical Center, 13603 100th Ave NE, Kirkland, WA 98034
Special thanks to William R.Widmar, DVM, Professor of Diagnostic Imaging, Purdue University

CLINICALLY IMPORTANT ANATOMY OF SMALL MAMMALS FOR DIAGNOSTIC

IMAGING
Natalie Antinoff, DVM, Dipl. ABVP (Avian)

Knowledge of normal radiographic and ultrasonographic anatomy of exotic companion mammals is

necessary to be able to recognize and diagnose abnormal appearances. Detailed applications and abnormal
findings will be presented in further sessions this morning.

FERRETS

Digestive System
The stomach is in the left cranial abdomen and can greatly expand. Ferrets can vomit. The small intestine
is about 180-200 cm; there is no demarcation between the jejunum and ileum. Ferrets lack an ileocolic
valve. The scent or musk glands (anal sacs) are located at either side of the anal canal (most ferrets are
descented and neutered before export to pet shops). Gastrointestinal transit time in ferrets is
approximately 3 hours.
 2

Liver, Spleen
The liver is comprised of 6 lobes, and is anatomically comparable to other mammals. There is a gall
bladder. Early lipidosis has been demonstrated to begin in ferrets in as little as 24 hours. Hepatic cysts of
varying sizes can occur, and polycystic disease has been reported. Neoplasia can also occur, and tumor
types are similar to other mammals. The most common hepatic neoplasm is lymphoma, which generally
will have a diffuse mottled appearance, whereas hepatocellular carcinoma will usually be focal (at least
initially). Lobectomy can be performed if the tumor is isolated to one to two lobes. Biliary pathology is
rare, but wall thickening and obstruction can occur. The spleen lies predominantly on the left side of the
abdomen, running along the greater curvature of the stomach, attached by the gastrosplenic ligament. The
spleen can vary greatly in size depending on age and state of health. The enlarged spleen can extend from
the upper left all the way to the lower right of the abdominal cavity. Isoflurane anesthesia can lead to
profound splenic enlargement.

Urogenital System
The kidneys are located retroperitoneally, and can easily be palpated in most ferrets. They are usually 2.4-
3cm in length, are fairly mobile within the abdominal cavity, and can usually be readily identified on
ultrasound. The bladder normally holds about 10ml of fluid at low pressure. Pathology of the urinary
bladder may also occur. Cystitis may lead to bladder wall thickening. Blood clots and calculi can also
occur. Probably the most common bladder-associated pathology is prostatic enlargement secondary to
adrenal disease. Less commonly, bladder wall neoplasms can occur.

Reproductive system
In females, the ovaries are caudal to the kidneys. The uterus is comprised of two long horns, a short
uterine body, and a single cervix. The vulva is small. In males, the penis contains a J-shaped os penis.
There is prostatic glandular tissue at the base of the bladder and surrounds the urethra.
Most ferrets are altered prior to purchase, and therefore the incidence of true reproductive abnormalities
in non-breeder animals is rare. However, in ferrets with adrenal gland disease, as a secondary effect of the
excessive hormones produced, prostatic enlargement can occur with subsequent urinary outflow
obstruction. The connection between the prostate and bladder may be very small or extremely large. If
there is prostatic enlargement, always look for adrenal enlargement. In females, if there is any uterine
remnant, than stump pyometra may also occur.

Respiratory System
The ferret trachea can be easily visualized for intubation. The left lung is comprised of cranial and caudal
lobes. The right lung has 3 lobes, the cranial, middle, and caudal. There is a 6th accessory lobe. Anatomy
is similar to that of most mammals. The respiratory system is elongated in comparison to most mammals.
Diseases of the respiratory tract in ferrets include heartworm disease, pneumonia (from viral/bacterial
infections), and neoplasia, any of which may present with dyspnea, rales and/or pleural effusion.
Sonographically, heartworm disease can be recognized by the presence of parallel lines within the heart,
while neoplasia will be evident sonographically as either one mediastinal mass or multiple lymph nodes
throughout the cranial and caudal mediastinum. Thymoma is also reported, and the author has also seen
one heart-based tumor in a ferret.

Cardiovascular System
The heart is located further caudally than most mammals, between the 6th and 8th ribs. There may be
periapical fat, creating the radiographic appearance of elevation from the sternum on a lateral view.
Cardiovascular diseases in ferrets include dilated cardiomyopathy, hypertrophic cardiomyopathy, a mixed
form of cardiomyopathy, valvular insufficiency, and valvular endocarditis (uncommon). Dilated
cardiomyopathy is the most commonly seen, but any cardiac disease that may occur in other species
should be considered a differential in ferrets.
 3

Musculoskeletal System
The ferret has short legs and an elongated body. A healthy ferret will have an arched back which may
become more prominent with ambulation. Loss of this arch may represent weakness or illness. The ferret
spine is extremely flexible, making spinal or disk injuries extremely rare. Unlike most mammals, the
ferret has 15 thoracic vertebrae, 5 lumbar, and 3 sacral vertebrae. There are 5 toes on each of the four feet,
also with non-retractable claws.

Endocrine System
The pancreas is bilobed. The right limb is larger, located along the descending duodenum. The left limb
extends between the stomach and spleen. The pancreatic ducts extend from the central area of the
pancreas to the duodenum. The most common pancreatic abnormality is islet cell neoplasia, “insulinoma”.
These tumors may be difficult to visualize as they can be quite small, but this should be considered a
differential for any nodule in the pancreas.

The adrenal glands lie cranial and medial to each kidney. The left adrenal gland is supplied by the
adrenolumbar artery; the adrenolumbar vein crosses the gland on the ventral surface. It ranges from 6-8
mm in length, 4.3(female) to 4.4(male) mm in width, and is oval in shape. The right adrenal gland is
almost always adherent ventrally to the caudal vena cava. Its blood supply comes from 3-5 vessels that
arise from the right renal artery, the right adrenolumbar artery, and the aorta. It ranges from 8-11 mm in
length, 4.1 (female) to 4.8 mm (male) in width, and is more elongate. Accessory adrenal tissue may be
present in some ferrets.

RABBITS

Digestive Tract
Rabbits are hind-gut fermenters, adapted to digest a low quality, high fibre diet consisting mainly of
grass. The gastrointestinal tract of rabbits is quite long, making up 10-20% of body weight. The stomach
is thin-walled, with a well-developed cardia and pylorus. Vomiting or eructation is not possible in the
rabbit due to the presence of a limiting ridge between the esophagus and the stomach. Food and caecal
pellets are always present in the stomach, and although 80% of the ingesta in a normal rabbit reaches the
cecum in 12 hours, because of coprophagy the stomach is still half-full after 24 hours of fasting. For these
2 reasons, fasting prior to surgery or procedures is neither necessary nor recommended. The duodenum
and jejunum are narrow, and at the end of the ileum there is the sacculus rotundus, a T-shaped junction
with the cecum and large intestine. This region is rich in lymphoid follicles, and also known as the
ampulla ilei or ileocaecal tonsil, and which is a potential site for impaction. The cecum is very large and
thin-walled, coiling three times upon itself within the abdomen, and has many sacculations (or haustrae).
It terminates in the vermiform appendix, which is also rich in lymphatic tissue. The cecum lies on the
right side of the abdomen. Caecal contents are normally semifluid. The cecum of rabbits holds 57% of the
dry matter of the large intestine. The colon is sacculated and banded. Colonic contractions separate
fibrous from non-fibrous particles, and fibre moves rapidly through for excretion as hard faecal pellets.
Antiperistaltic waves move fluid and non-fibrous particles back into the cecum for fermentation. Three to
eight hours after eating, and thus mainly at night, soft, mucus-covered caecal pellets are expelled and
eaten directly from the anus (a process known as cecotrophs, coprophagy, refection, or pseudo
rumination). Arrival of the cecotrophs at the anus triggers a reflex licking of the anus and ingestion of the
cecotrophs, which are swallowed whole and not chewed. A muscular band of richly innervated tissue with
a thickened mucosa, the fusis coli, lies at the end of the transverse colon and acts to regulate colonic
contractions and controls production of the two types of pellets.
 4

Radiology and Ultrasonography of the Digestive Tract

The stomach and small intestines can be visualized sonographically unless filled with air. Rugal folds can
be seen in many patients. As many as 4 layers of the small intestine can be identified – the mucosa,
submucosa, muscularis, and serosa. The wall should be less than 3 mm thick. The colon can also be
identified, but only 3 layers can usually be seen. This should be less than 1mm thick. The cecum is often
gas filled and may impede visualization of other structures. The contents are usually semifluid and may
have a particulate or ‘stellate’ appearance. Lymphoid tissue cannot be sonographically identified.

Digestive Tract Disease

Gastric or intestinal obstruction, ileus (mechanical, metabolic and also thromboembolic), can be identified
using radiology, often without contrast media. Functional ileus is far more common in rabbits and usually
less severe. With mechanical ileus (obstructive disease), as a general rule, there will be 2 distinct bowel
populations evident, as bowel that is orad to the obstruction will be markedly dilated, but aborad will
appear normal. The most common sites for obstruction are the stomach and the sacculus rotundus. Gastric
obstruction is usually diagnosed radiographically. Obstruction at the sacculus rotundus does not produce
characteristic 2 bowel populations due to its location at the termination of the ileum. Infiltrative diseases
of the bowel are uncommon but may occur, typically creating a focal mass effect.

Liver, spleen, pancreas, adrenals

The pancreas is diffuse and located in a pocket formed by the transverse colon, stomach and duodenum.
Pancreatic diseases of rabbits are uncommon and are not emphasized in abdominal sonograms of this
species. The spleen is small, flat and elongated and lies on the dorsolateral surface of the greater
curvature of the stomach. It is difficult to evaluate sonographically, and splenic abnormalities or diseases
are extremely rare. The adrenal glands of rabbits are large relative to body size. The liver has four lobes.
A gall bladder is present, and rabbits secrete mainly biliverdin in the bile rather than bilirubin. The
pancreatic duct and the bile duct are separate. There is a gall bladder.

Ultrasonography of the liver, adrenals

Sonographically, the liver should be hyperechoic when compared to the spleen, with sharply tapering
margins. Decreased echogenicity of the liver parenchyma may indicate disease. Differentials should
include neoplasia (such as lymphoma) or cardiovascular disease. Venous congestion would be consistent
with right sided cardiac disease. Hyperechogenicity is consistent with hepatic lipidosis, cirrhosis, or
lymphoma. Hepatic lipidosis in rabbits may be difficult to differentiate from other pathology with
ultrasonography. Hepatic cysts of varying sizes can occur. Neoplasia can also occur, and tumor types are
similar to other mammals. Biliary pathology is rare. The location of the adrenal glands is similar to
ferrets. Pathology of the adrenal glands is extremely rare. The author has seen two adrenal masses in
rabbits, both of which were at least three times the size of the contralateral gland.

Reproductive system
Does have long curved uterine horns, two separate uterine horns and two cervices opening into the
vagina. The vagina is large and flaccid, and a vaginal vault may be identified even in spayed females.
Most female rabbits will develop a large amount of mesometrial fat. The females have 4 to 5 pairs of
mammary glands and nipples. The placenta is hemochorial. Bucks have two hairless scrotal sacs on
either side and cranial to the penis. There is no os penis. The inguinal canals remain open throughout life.
Male rabbits lack nipples. There is a prostate gland, but it is rarely identified.

Ultrasonography of the Reproductive System

Sonographically, the uterus can be identified as a tubular structure between the colon and the bladder, that
lacks gas and peristalsis. It can usually be traced to the ovaries, that lay caudally to the kidney on either
side. Pathology of the uterus is common. Although neoplasia is the most common pathology,
endometriosis and aneurisms may both occur. Normal pregnancy can also be identified. Male
 5

reproductive pathology is uncommon, although testicular neoplasia is reported. More commonly, since
the testicles can freely ascend back into the body, an inexperienced veterinarian may believe an animal to
be cryptorchid and only neuter one side. The second testicle then may be located abdominally or may
become diseased later in life. The prostate gland is rarely identified, and the author is aware of no reports
of prostate disease in rabbits.

Urinary System
Rabbit kidneys are unipapillate. The urethra of the female rabbit empties in to the proximal end of a deep
vaginal vestibule. Expression of the bladder when the animal is in dorsal recumbancy can lead to retro-
filling of the vaginal vault, which may be a source of confusion when performing ultrasound of the female
reproductive system. Urine is the major route of excretion for calcium. Rabbit urine is often thick and
creamy due to the presence of calcium carbonate crystals. The calcium excreted in the urine may lead to a
chalky or cloudy appearance to the urine, and calcium carbonate or calcium oxalate crystals may routinely
be present in normal urine. It can also vary in color from pale creamy yellow through to dark red (often
mistaken for hematuria by owners), due to the presence of porphyrin pigments thought to be derived from
the diet. As herbivores, the pH of normal rabbit urine is 8 to 9.

Radiology and Ultrasonography of the Urinary System

Radiographs are useful to identify mineralizations, nephroliths, calculi, bladder sludge, and absolute sizes
of the kidneys and bladder. Sonographically, the kidneys consist of a cortex, medulla, a renal pelvis, and a
renal sinus. The renal pelvis may have a stellate appearance. The urinary bladder is similar to that of other
species. There may be diffuse cortical hyperechogenicity (inflammatory or age-related), renal masses, or
infarcts. Diffuse stellate foci in the cortex may be a sign of past Encephalitozoon cuniculi infection.
Nephroliths may occur, resulting in hydronephrosis. Pyelonephritis and renal mineralization may also
occur. Pathology of the urinary bladder may also occur. Cystitis may lead to bladder wall thickening.
Calculi can also occur. Probably the most common bladder-associated pathology is cystitis with wall
thickening secondary to chronic calciuria.

Respiratory and Cardiac (Thoracic) Anatomy

Rabbits are obligate nose-breathers.This is an extremely important clinical feature, as even brief occlusion
of the nares can lead to respiratory arrest. The glottis is small, deeply recessed in the oral cavity, and
visually obscured by the muscular ridge of the tongue (the torus). Reflex laryngospasm is common in the
rabbit, which can complicate endotracheal intubation. The trachea itself is narrow relative to body size.
The thoracic cavity is small in comparison with the large abdominal cavity, and breathing is mainly
diaphragmatic. The lungs have three lobes, and the cranial lung lobes are small (left smaller than right).
Significant respiratory compromise may occur if a rabbit is placed in dorsal recumbancy when the
stomach or cecum are greatly distended. Large amounts of intrathoracic fat are often present. The thymus
persists in the adult rabbit and lies ventral to the heart, extending in to the thoracic inlet. Diseases of the
respiratory system are most often infectious in etiology. Abscesses of the lungs may occur and may have
the appearance of multiple masses, mimicking metastatic disease. Pleural effusion may occur as a result
of chronic pneumonia or lower respiratory infection. Thoracic masses generally are either thymoma or
lymphoma.

The heart is relatively small and lies cranially in the thoracic cavity. Both the right and left
atrioventricular valves are bicuspid and consequently are named the right and left a-v valves. The heart
itself is small relative to total body size, comprising only 0.3% of the total body weight. Rabbits have the
most muscular pulmonary artery of any species, which contributes to their predisposition for pulmonary
hypertension. The rabbit aorta has neurogenic rhythmic contractions. Other vessels in rabbits are thin-
walled, frequently leading to collapse and hematoma formation with venipuncture. The external jugular
vein provides the main route for venous drainage from the head, as compared to the internal jugular vein
in most mammals. There is a lack of anastomoses between the external and internal jugular veins. The
 6

clinical significance of this feature is that ligation or thrombosis of the external jugular vein can lead to
temporary exophthalmos. Ligation of the external carotid artery will cause ocular necrosis on that side.

Radiology and Ultrasonography of the Thorax

Ultrasonography of the thorax is problematic due to the presence of air in the lungs. Ultrasonography may
be useful as an adjunct to radiology where there appears to be fluid or solid densities within the thoracic
cavity. Positioning of a dyspneic rabbit for ultrasonograhy requires the same cautions as with radiology.
Positioning the patient on a tilt table or elevating the thorax with towels or pillows can decrease the risk
of respiratory compromise for imaging. Large amounts of intrathoracic fat are often present and can be
differentiated with ultrasonography from fluid or probably neoplasia or abscess.

Echocardiography
Sonographic evaluation of the heart is comparable to other mammals. Cardiac disease is underdiagnosed
in older rabbits, although cardiomegaly, aortic or other vascular mineralization, pulmonary edema or
thoracic fluid, hepatomegaly with venous congestion, can be imaged using radiology and
ultrasonography. There are published normal echocardiographic measurements for rabbits. The rabbit
heart can be imaged with the rabbit placed sternally similarly to a dog or cat.

Musculoskeletal System
The vertebral formula of the rabbit is C7 T12 L7 S4 C16. Thirteen thoracic vertebrae are seen in some
animals. The musculoskeletal system of rabbits is unique in several aspects. The bones of rabbits are
much lighter than most other species, comprising only 8% of the body weight, as compared to 12 to 13%
in cats. The bones have thin cortices and are easily shattered. The hind limbs are longer than the forelimbs
and the gluteal and hind limb musculature is extremely well developed. The forelimbs have five digits but
the hind limbs only have four. The nails are long and narrow for digging and burrowing, but are not
retractable, and rabbits should not be declawed. The powerful hind limb musculature and light skeleton
enable powerful jumping over long distances; however, the longer spinal column is more prone to
luxation with a powerful kick or struggle if the hind end is not well supported during restraint. The
musculoskeletal system is primarily evaluated using radiographic techniques although computed
tomography can be utilized as will be discussed later in this seminar.

GUINEA PIGS AND CHINCHILLAS

In many aspects these two species are anatomically similar, so they will be discussed together.
Differences will be identified. Ultrasonography is not the imaging method of choice for gastrointestinal or
thoracic disease in these species. Radiographic imaging may be more diagnostic.

Digestive System
The stomachs have a glandular epithelial lining. The intestinal tracts of both species are long, with a
prominent cecum. The cecum contains longitudinal bands, taenia coli, which form lateral sacculations.
The cecum of guinea pigs holds 44% of the dry matter content of the large intestine. Gastric emptying
time of guinea pigs is 2 hours, with GI transit time of approximately 20 hours. Coprophagy can prolong
transit time. Some older male guinea pigs can develop fecal retention or impaction in the anal region,
which may represent a loss of muscle tone, and may require periodic cleaning. The cecum of chinchillas
is smaller than guinea pigs, holding only 23% of dry matter content of the large intestine. Both species
practice coprophagy.

Gastric or intestinal obstruction, ileus (mechanical, metabolic and also thromboembolic), can be
identified. (See description under rabbits). Intestinal obstruction overall is rare in these species. Gastric
distension/bloat can occur in guinea pigs, and is usually more readily diagnosed radiographically. Similar
 7

to bloat in dogs, this is usually not the result of a mechanical obstruction, but rather entrapment of air
secondary to another disease process causing pain or ileus. Infiltrative diseases of the bowel are rare but
may occur, typically creating a focal mass effect.

Urogenital
Male guinea pigs have an os penis. The inguinal canals are open. There are large paired vesicular glands
that extend for up to 10 cm in the abdominal cavity and can be mistaken for uterine horns. Female guinea
pigs have paired uterine horns and a single cervix. Male chinchillas lack a true scrotum, and the testes are
freely mobile. There is no os penis but the penis is easily exteriorized. Female chinchillas have paired
uterine horns and two cervices. Females have a large urogenital papilla which is frequently mistaken for a
penis. The most reliable method for sexing chinchillas is the anogenital distance, which is greater in
males. Urine of both species is alkaline and may have crystals.

Ultrasonography of the Reproductive Tract

By far the most commonly diagnosed reproductive disorder in female guinea pigs is cystic ovarian
disease, which is frequently bilateral and usually associated with abdominal distension and bilaterally
symmetrical alopecia. Male reproductive pathology is uncommon, although testicular neoplasia may
occur. More commonly, the seminal vesicles are mistakenly identified as pathology. These will appear as
bilateral tubular soft tissue opacities dorsal to the bladder, which may also have hypoechoic or anechoic
fluid.

Endocrine
Guinea pigs have the largest adrenal glands relative to body size of any mammalian species. The adrenals
are paired, oval, and located cranioventral to either kidney. The left adrenal gland is more elongated and
has a concave surface dorsally where it contacts the renal vessels. The right adrenal gland also has the
concave surface, but is not in contact with the vessels. In cross-section, both adrenal glands will have a
triangular appearance. Sonographically, the adrenals are located by first locating the kidneys. Adrenal
neoplasia is reported in guinea pigs.

Thoracic Anatomy
Respiratory
The right lung is comprised of the cranial, middle, caudal, and accessory lobes. The left lung is comprised
of a cranial, middle, and caudal lobes. In both species, the thoracic cavity is small in comparison to the
abdominal cavity. Diseases of the respiratory system are most often infectious in etiology. Abscesses of
the lungs may occur and may have the appearance of multiple masses, mimicking metastatic disease.
Pleural effusion may occur as a result of chronic pneumonia or lower respiratory infection

Cardiovascular
The right a-v valve is tricuspid, and the left is bicuspid. Mild heart murmurs may be present in chinchillas
without significant cardiac disease. Congenital cardiac defects have been found in both guinea pigs and
chinchillas. Cardiomyopathies may also be found in geriatric animals, and in cases of Vtamin C
deficiency in guinea pigs. Sonographic evaluation of the heart is comparable to other mammals. Although
cardiac disease is rarely documented, the same diseases as other species are all possible. The author has
seen several cases of dilated cardiomyopathy and valvular insufficiency; most of these have responded
very well to therapies utilized in other companion animal species.

References: Available from the author.

 8

Anesthesia for Radiology of Exotic Companion Mammals

Angela Lennox, DVM, Dipl. ABVP (Avian)

Anesthesia is frequently used to facilitate collection of high quality diagnostic images in exotic
companion mammals, especially in those patients for which manual restraint is stressful or risky.
Traditionally isoflurane via facemask with or without the addition of a pre-anesthetic agent represents the
most common choice reported in exotic animal literature. Increased concern over human exposure to
waste anesthetic gas, and the availability of safer injectable agents give exotic practitioners more
flexibility when choosing an anesthetic protocol for collection of diagnostic images. Choice depends on
anticipated length of the procedure, patient demeanor and condition, and availability of agents and
administration routes.

Options for radiology include:

Manual restraint
Manual restraint requires practice and can be useful in selected situations, but can be stressful. It also
requires careful collimation to avoid hands and gloves in the primary beam.

Anesthesia/sedation:
-Isoflurane as a sole agent delivered via facemask or anesthetic chamber
-Combination pre-anesthetic with or without the addition of analgesic with isoflurane delivered via
facemask.
-Injectable sedation with manual restraint
-Injectable anesthetic agent

The most practical application of sedation is for radiography of the critical or less stable patient. The most
striking example is for radiography of rabbits or rodents in respiratory distress. Low dose sedation has
minimal respiratory/cardiovascular depressant effects, and often relieves the anxiety associated with
distress, in effect improving patient condition.

Disadvantages of simple gas anesthesia via facemask:

- Increased stress during induction
- Increased exposure of staff to waste gas
- Apnea and potential hypotension, which is dose related in isoflurane
- Interference of mask for radiography of the head in patients that cannot be intubated

Midazolam
IM administration: Excellent pre-anesthetic agent to reduce stress of mask induction or reduce volume of
injectable agent required; may be enough in very calm patients to facilitate manual restraint. Outstanding
safety.
IV administration: Provides brief deep brief (less than 10 minutes) sedation often adequate as a sole agent
even in fractious patients. Requires IV administration. Outstanding safety.

Domitor/Ketamine
Effects are highly dose dependant and vary from species to species. Lower pre-anesthetic doses may be
adequate for use as a sole agent. Higher dosages provide long term anesthesia ideal for longer
procedures. Domitor is hypotensive and not recommended for ill or critical patients.

Etomidate
Induction agent with outstanding safety features, but requires IV administration and concurrent
administration of a benzodiazepine.
 9

References and Useful Resources:

1. Capello V, Lennox A. Widmar R (ed): Clinical Radiology of Exotic Companion Mammals. Blackwell
Publishing, in press 2008
2. Flecknell, P (ed). Manual of Rabbit Medicine & Surgery, BSAVA, Quedgeley, Gloucester, UK, 2000,
various chapters
3. Lichtenberger M, Ko J. Anesthesia and analgesia for small mammals and birds. Vet Clin Exoti Anim
10 (2007)293-315.

Table 1. Suggested selected drug dosages for sedation and anesthesia of small exotic mammals

Drug Dosage Comments

Midazolama
(sedation, pre-anesthesia)
Medetomidine/Ketaminea
(sedation, pre-anesthesia)
0.25-0.50 mg/kg Often provides excellent relaxation
IM or IV for phlebotomy or other minor
procedures, or to facilitate less
stressful induction with inhalant
agents.
M: 0.1 mcg/kg Rapid sedation often adequate for
K: 2 mg/kg brief, minor procedures. May
require supplemental isoflurane.

Medetomidine:Ketamineb 80-120ug/kg:25-30 Reverse with Atipamezole at the end

(anesthesia; reduce slightly when used with mg/kg (rabbit) of the procedure; dosage is 5 times
isoflurane) 50-70 ug/kg:20-25 the Medetomidine dose used (not 5
mg/kg (guinea pig) times the volume).
100ug/kg:30
mg/kg (rodent s)

Etomidatea 1 mg/kg IV Outstanding safety, but requires IV

(anesthetic induction) administration. Is an induction agent,
therefore effects are short-lived
when used alone. Must be used with
a benzodiazepine to prevent seizure

Isoflurane Commonly used as sole anesthetic

(anesthesia) agent. Induction is less stressful with
premedication with midazolam.
Sevoflurane See above. Most anecdotal reports
(anesthesia) indicate this agent is not
overwhelmingly superior to
isoflurane, and is considerably more
expensive
a. Marla Lichtenberger, personal communication
b. Vittorio Capello, personal communication
 10

Radiography of Exotic Companion Mammals

Vittorio Capello, DVM
Introduction
Radiography is a very useful diagnostic tool in veterinary medicine, and is no less importance in exotic
mammal medicine. Production of high quality diagnostic images requires some skill and practice, and is
possible with most standard radiography equipment, and careful pre-planning. Poor quality radiographs
are difficult to interpret and may result in misdiagnosis. These proceedings will not attempt to delve
deeply into basic principles of diagnostic imaging, but will highlight differences and modifications of
importance to the exotic animal practitioner.

Equipment for Standard Radiography of Exotic Companion Mammals

Certain features are useful for obtaining high quality images of exotic animals, in particular small exotic
mammals.
Cassettes: High detail, low speed
Film: slow to ultra-slow film (mammography film)
Equipment: Use of slower film and cassette combinations necessitates increased exposure (mAs).
Mammography film may require up to 25 times the mAs of par or high speed combinations. mAs may be
increased through increasing mA, or by increasing time in seconds (s). Many veterinary radiographic
machines are preset with a fixed, lower end mA, often as low as 20 mA, which is suitable for most
veterinary use. However, when a machine with a low preset mA is used with mammography or other
slow film, the only way to obtain higher mAs is to increase exposure time. Increased exposure time
increases the risk of movement artifact, especially from rapid spontaneous breathing movements in
smaller exotic patients. The ideal machine, therefore, has an adjustable mA, ideally in the range of 5.0 to
20.

Very few practitioners are faced with ancient radiography equipment without collimators or other modern
functions. Careful collimation over the area of interest allows increased image quality, reduces dispersion
of x-rays (scatter), and increases operator safety, especially when using manual restraint techniques

Digital Radiography (DR)

Digital Radiology represents a significant advancement in clinical radiology. The largest overall
advantage is reduced time spent producing an image. Patient handling, restraint and radiographic
technique remain the same. There are two broad classifications:

CR – computed radiography – imaging plates and a plate reader are used to generate an image

DDR – direct digital radiography – imaging plates are not used and the images are available immediately
without a processing step.

CR represents somewhat of a hybrid between conventional radiography and direct digital radiography
(DR). Computed radiography systems replace the film, intensifying screen, and cassette used in
traditional radiography systems with an imaging plate. Additionally, the wet film processor used in
conventional radiography is replaced with a digital imaging reader. The steps of obtaining a digital
radiography with a CR system are as follows:
a) The imaging plate is placed in the bucky tray
b) An exposure is made
c) The imaging plate is removed from the bucky tray and placed in an imaging reader. Inside the imaging
reader, the imaging plate is exposed to a series of laser lights that read the information on the plate and a
radiograph appears on a computer monitor. (this conversion to light represents an analog process so
 11

computed radiography is not, technically, completely digital.)

d) The imaging plate is "erased" inside the imaging reader and is ready to use for another exposure.
Depending on the imaging reader, it takes about 90 seconds to read and erase each imaging plate, which is
similar to the time required for a conventional film processor.

CR Advantages
- A digital image is generated
- Ability to retrofit to existing radiography equipment
- Can be used with mobile radiography units
- Excellent image quality
- Initially less expensive than DR

CR disadvantages
- Still requires an imaging plate
- No real time saving benefit over traditional radiography
-Must purchase an imaging reader
-There is no immediate feedback after the exposure

Direct digital radiography (DR) is a method of digital radiography where the conventional radiographic
cassette and film are replaced with a digital imaging sensor. This imaging sensor is either permanently
affixed to an x-ray table or attached to the DR computer by a wire. Currently there are no viable wireless
systems.
The steps involved in obtaining a DR image are follows:
- The imaging sensor is exposed by x-rays
- An image appears on the computer screen

DR Advantages
- No processing time and immediate image acquisition
- Excellent image quality

DR Disadvantages
- More expensive than CR
- Mobile radiography will require a wire between computer and imaging sensor

Advantages and Disadvantages of Digital Radiography vs. Traditional Radiography:

Benefit number 1 - Decreased Long-Term Costs

- No film costs
- No processor to maintain
- No film jackets to purchase
-No physical storage requirements
Initial cost is high; however the system is expected to pay for itself with time and frequent use.

Benefit number 2 - Decreased Retakes: In human medicine digital radiography has decreased the number
of retakes dramatically which increases efficiency and decreases costs. In theory, digital radiography
allows you to decrease retakes because there is increased latitude of the imaging system (i.e. digital
radiography is more forgiving of exposure problems). However, it should be kept in mind that digital
radiography often actually results in an increased number of retakes, as ease and instant results
encourages retakes when images are not optimal.
 12

Benefit number 3 - Decreased Radiation Dose to the Patient and Personnel: Manufacturers claim that
digital imaging systems need less radiation to function properly. However, in practice exposure may
actually be increased. If the image produced is overexposed (too black) digital radiography systems, do a
good job of "windowing down" to see the information on the image and there is no need to repeat the
exposure. Conversely, if the image is underexposed (too white) the system cannot retrieve any
information form the white areas and the exposure must be repeated. Technicians (and vet students) learn
this very quickly and often simply increase the exposure so it can be remedied later.

Benefit number 4- Increased efficiency

While this is a likely benefit in human medicine, in veterinary medicine there is still considerable time
spent for set up and restraint (pharmacological or manual); therefore increases in efficiency may not be
as significant.

Benefit number 5- Increased Interactivity with Referring Clinicians

Exchanging digital images is much easier than mailing traditional radiographs.

Benefit number 6- No Lost of Damaged Films

This benefit assumes an adequate back up system preventing loss of digital data

Benefit number 7-Instant post-collection manipulation of the digital image.

Images can be adjusted, cropped and magnified immediately after acquisition. This can be accomplished
with traditional radiographs, but only after scanning, which is considerably more time consuming.

Problem 1- Cost
From the QUANTITY standpoint, only clinicians using radiography frequently can justify this system.
Many users find that the advantages encourage more frequent usage.

Problem 2-Unhappy Orthopedic Surgeons

Some surgeons do not prefer digital systems for two reasons: First, it is difficult to measure for an implant
on a computer screen. An actual radiographic film provides images in real size, while the monitor does
not. Some also report more artifact associated with metal implants, and difficulty detecting infection
around the implant.

Problem 3-Old technology: This is a general problem plaguing all computer-based technology; current
technology becomes obsolete so quickly that it is hard to invest in something that will take years to see a
return. The best systems allow affordable upgrades, and will be able to be serviced in years to come.

Note that nowhere in the description of digital radiography does it state that it necessarily produces higher
quality images than those produced by traditional radiography, especially in very small exotic animals.
Quality is often better, as instant results allow easier adjustments and encourage retakes of less than
optimal images. Many systems cannot produce images of small exotic animals that are better quality than
those produced with mammography film and low speed cassettes. Exotic animal practitioners must
carefully evaluate the capability of each system before purchase.

Obtaining the Radiograph

Diagnostic radiographs require proper equipment, proper technique, and a cooperative, still patient.
Equipment selection has been discussed above. Sedation and anesthesia techniques are described in detail
below.
 13

Developing a Technique Chart for Exotic Species

With the exception of larger species such as the potbellied pig, most exotic mammal patients are placed
directly on the cassette, and the bucky tray is not utilized. Once the patient is properly positioned on the
cassette, standard measurements are made to determine kVp and mAs. Many manufacturers of
radiographic equipment supply technique charts for traditional companion animals based on tissue type,
such as thorax, extremities, and abdomen, and on measurement of the area of interest. However, most
cannot supply technique charts for unusual species, or for unusual film/screen combinations such as
mammography film. It is important, therefore for the practitioner to begin developing a unique technique
chart for all exotic species commonly encountered in practice, often based on trial and error. It must be
kept in mind that a technique chart for a specific film/cassette combination based simply upon
measurement of the area of interest is often inadequate for the exotic animal practitioner, as the tissues of
herbivorous and carnivorous mammals are often very different, for example, the abdomen of the rabbit vs.
the abdomen of a ferret. The best solution is a technique chart based on film/cassette combination, species
and measurement of the area of interest. Practitioners can speed to process of establishing an optimal
technique chart by making serial radiographs on cadavers of commonly encountered species.

Preparing the Patient for Radiography

Initial decision-making for preparing the patient for radiography involves determination of overall patient
condition, and estimating the time required to complete the entire procedure, including allowing time for
a quick review of the radiographs to be certain they are useful and of diagnostic quality.

The clinician should therefore:

Determine if patient condition will allow stress and handling of the radiographic procedure
Determine if the patient can be safely radiographed using manual restraint with or without sedation, or
whether anesthesia will be required.
Determine the ideal anesthetic protocol (if needed) based on patient condition, availability anesthetic
agents, estimated length of procedure, and other factors such as the ability to intubate, or interference of
an anesthetic cone with collection of the image.

Patient Positioning for Radiography

Expert manual restraint, sedation and/or anesthesia are often necessary for collection of diagnostic quality
radiographs in exotic mammal species, and is discussed above. As in any other species, image quality is
negatively affected by poor positioning. Examples include inadvertent omission of the area of interest
from the area of collimation, superimposition of structures, lack of symmetry, failure to collimate on the
area of interest, and patient movement.
Symmetry is an extremely important factor in patient positioning, with the exception of oblique or other
special projections. Contoured pieces of radiolucent foam are useful to obtain proper positioning. Heavier
devices like sandbags are rarely used in exotic mammal patients. Radiolucent tape is useful for securing
patients directly onto the cassette or the radiographic table.
Standard views include lateral, dorsoventral or ventrodorsal, rostrocaudal and anterioposterior /posterior-
anterior views, and various oblique projections. “Whole body” radiographs are common in smaller exotic
species. Attempts to collect whole body radiographs in larger species are not recommended, as the
technique (in particular kVp) will not be ideal for all sections within the imaging area.

Putting It All Together for Optimal Radiographic Images

Production of the highest quality radiographs requires attention to following details:
-The patient must be properly anesthetized or safely restrained manually to limit patient motion
-Optimal screens and films must be selected based on patient size and diagnostic goal
-The object of interest must be centered in the image
 14

-The patient must be properly positioned according to requirements of the desired projection
-All projections required for that radiographic study must be acquired rapidly and efficiently. The “right”
and/or “left” aspect of the patient should be clearly labeled. Markers must be incorporated in the
radiographic exposure and not handwritten on the finished radiograph.
Oblique projections must be labeled according to beam entry and beam exit, to avoid misidentifying the
site of a lesion.
Identification must occur in conjunction with the x-ray exposure. Handwritten identification made on the
finished radiograph will lead to errors and will not satisfy legal requirements.
-The identification label should not obscure the area of interest
-Apparatus associated with the patient such as tubes, monitoring equipment, etc. must not obscure the
area of interest
-Other external objects such as collars, or the hands of the operator must not appear in the image
- In the authors’ experience, the best images of smaller exotic patients are made with low speed
cassettes and mammography film, with a radiographic machine capable of higher mA settings.

References and Useful Resources:

1. Capello V, Lennox A. Widmar R (ed): Clinical Radiology of Exotic Companion Mammals. Blackwell
Publishing, in press 2008
2. Silverman S, Tell LA. Radiology of Rodents, Rabbits and Ferrets. An Atlas of Normal Anatomy and
Positioning. Philadelphia (PA): Elsevier Saunders; 2005.

Introduction to Ferret Ultrasound

Michelle H. Fabiani, DVM, Dipl. ACVR

Basic Principles of Ultrasonography

Instrumentation
Successful ultrasonography is not only dependent upon the ultrasonography for interpretation, but on the
equipment utilized. The transducer (also called a scanner or probe) must be selected for the highest
frequency (resolution) that will penetrate to the depth needed for the particular examination. For ferrets,
7.5 MHz-14 MHz are the most useful. Multi-frequency transducers available for many types of machines
generally have the disadvantage of slower frame rates. The axial resolution is the ability to separate points
along the length of the transducer. All measurements should be taken in the length of the transducer, not
the width. The focal zone of the transducer is the acceptable lateral resolution several centimeters along
the beam axis, on either side of the focal point. There are two major types of scanners. A sector scanner
results in a pie-shaped image. A linear scanner results in a rectangular image field. The control knobs on
the ultrasound machine’s console can be manipulated to produce uniform brightness throughout the near
and far fields of the image. The Power and Gain knobs will increase the amplitude of returning echoes
and should be set low to prevent artifacts. The Time Gain Compensation controls (lateral slides) are used
to equalize echoes returning from different depths. Echoes returning from deeper structures are weaker
than echoes arising from superficial structures due to increased sound attenuation. The near gain control
functions to suppress strong echoes from superficial structures in the near field. The far gain control
increases weak echoes from structures in the far field.

There are two main modes of echo display – the B-mode and the M-mode. The B-mode is the Brightness
Mode. The display is of returning echoes as dots that the brightness or gray scale is proportional to the
amplitude of the returned echo. The position corresponds to the depth at which the echo originated along
a single one. The M-mode is the Motion Mode. A single line of B-mode dots is swept across the video
 15

monitor. The motion of the dots represents the change in distance of reflecting interfaces from the
transducer and is recorded with respect to time.

Image Interpretation and Recognition of Artifacts

The image projected on a video monitor is oriented so that the top of the image represents the skin
surface. Convention orients cranial to the sonographer’s left. Transverse views should be oriented similar
to a VD radiograph with the left on the sonographer’s right. The term “echogenicity” refers to the amount
of echoes returning. Echogenic is also called hyperechoic and indicates an area of high echo intensity.
Echo poor is also called hypoechoic and indicates an area of low echo intensity. Anechoic is the lack of
internal echoes. Echotexture is used to indicate parenchyma texture. Fine parenchymal texture is shown as
small dot size on B-mode (i.e. spleen) while coarse texture is large dot size on B-mode (i.e. liver).
Artifacts frequently occur and need to be recognized. Mirror image artifacts occur when a large reflector
such as the diaphragm-lung interface is encountered. This may result in an error in interpretation of the
location of an organ or structure. Slice thickness artifacts occur when part of the ultrasound beam’s width
(thickness) is outside the cystic structure. This results in the presence of “pseudo-sludge” seen in the
urinary bladder or gall bladder. Shadowing is an area of low-amplitude echoes created by structures of
high attenuation. Where soft tissue and gas interfaces, 99% of the sound is reflected and the resulting
shadow appears “dirty” (inhomogeneous). Soft tissue-bone interface may reflect 66% with the rest
absorbed that results in a “clean” (uniformly black) shadow. Enhancement artifact represents a localized
increase of echo amplitude occurring distal to a structure of low attenuation. This may help to
differentiate hypoechoic solid masses from cystic structures. Reverberation occurs when sound is entirely
reflected back from gas. It will bounce back and forth between the probe and the gas, creating multiple
echoes from one ultrasound pulse. It will appear as multiple parallel lines.

Doppler
The Doppler effect results from an apparent shift in sound frequency as sound waves are reflected from
moving targets, usually blood cells. The Doppler shift is the difference between the transmitted and
received frequencies. The greater the Doppler shift, the greater the velocity. Color Doppler is useful for
determining blood flow. Yellow, orange and red indicate flow toward the transducer. Blue and green
indicate flow away from the transducer. Pulsed-wave Doppler allows for depth discrimination.
Continuous-wave Doppler measures higher flow velocities. All flow will be measured along the entire
beam regardless of depth. This is often used for cardiac measurements. Above the baseline flow is toward
the transducer while below the baseline flow is away from the transducer. Artifacts can occur with
Doppler. In pulsed or continuous-wave, the highest velocities may seem to “wrap around” and show up
on the opposite side of the baseline. When the velocity exceeds the colors available, “wrap around”
occurs with the yellow showing adjacent to green.

Abdominal Ultrasonography of the Ferret

Liver
The normal liver is comprised of four lobes and four sub-lobes. The left lobe comprises 1/3 to ½ of the
total hepatic mass. It is divided into medial and lateral sub-lobes. The quadrate lobe is on the midline,
adjacent to the left side of the gall bladder. The right lobe is adjacent to the right side of the gall bladder.
It is divided into medial and lateral sub-lobes. The caudate lobe surrounds the cranial pole of the right
kidney. It has both a caudate and a papillary process. These two processes have an isthmus, that passes
between the caudal vena cava and portal vein. It is often in close association with the right adrenal gland.
Hepatomegaly is suspected with caudal displacement of the stomach and when the caudate lobe entirely
surrounds the right kidney. The parenchyma of the normal liver has uniform echogenicity. Its echotexture
is more coarse when compared to the spleen, and more echogenic than the cortex of the right kidney. The
portal vein is superficial to the caudal vena cava. It has both a right and left branch. The walls are
echogenic and it is usually easily visualized. Hepatic veins may also be seen and differentiated by the lack
 16

of echogenic walls. Hepatic veins empty into the caudal vena cava. The gall bladder normally contains a
small amount of echogenic sediment in the lumen. With anorexia or fasting, a large amount of bile may
accumulate. Intra-hepatic biliary ducts are not visible. In some previously fasted ferrets, administering
food during ultrasonography may stimulate the gall bladder to release bile into the duodenum. The
ejection may be visualized.

Hepatic, Gallbladder and Biliary Disease

Tissue samples for diagnosis of liver disease are best obtained with biopsy rather than guided needle
aspirates.3 Diffuse disease that indicates widespread parenchymal abnormalities may image as coarse
echotexture. Hepatomegaly is usually present. Decreased echogenicity may be seen in lymphoma, acute
(suppurative) hepatitis, passive congestion and congestion due to right heart disease (heartworms, DCM).
Increased echogenicity may be present due to hepatic lipidosis, chronic (lymphocytic) hepatitis, cirrhosis,
or lymphoma. Focal liver disease may appear as irregular serosal margins, particularly if peripheral
masses deform the liver capsule. Nodular hyperplasia usually images as well-defined hypoechoic
structures. The liver parenchyma may be isoechoic or hyperechoic. Cysts may be seen with thin, well-
defined walls, no internal echoes, sharp distal borders, peripheral refractive zones and strong distal
acoustic enhancement. Cysts may be congenital or acquired. They may form due to trauma or
inflammatory disease. They usually do not change in size over time. Cyst-like structures originating from
the biliary tract may occur. Irregular walls, septations and/or internal debris may be present. Cystic biliary
adenocarcinoma may image as an almost sponge-like, bubbly conglomeration of cysts with distortion of
normal parenchyma and vasculature. Toxic, inflammatory or other neoplastic diseases may contribute to
cystic structures in the liver. Serial examinations will show changes in size over time. Hematomas have
been diagnosed in ferrets in the liver tissue. Acutely these are echogenic with irregular margins. They will
have a variable appearance over time. Abscesses appear with hypo- or anechoic centers and an echogenic
rim. Margins will be irregular. They may be hard to differentiate from a neopastic process, particularly if
there is a liquefied or necrotic component. Primary neoplasias include hepatomas, hepatocellular
adenocarcinoma, biliary adenocarcinoma.3 Metastatic tumors are more common than primary and include
adrenal adenocarcinomas, leiomyosarcomas ad lymphomas. Ultrasonography cannot differentiate primary
from metastatic neoplasia. Lymphoma must be considered in any ferret with hepatomegaly, even if the
liver appears ultrasonographically normal. Vacuolar hepatopathy has been associated with adrenal
tumors.3 Biliary obstruction may appear as a dilation of the biliary tract retrograde following complete
obstruction. Gall bladder enlargement occurs first. Extra-hepatic ducts dilate within 48 hours with intra-
hepatic ducts dilating in 5-7 days. Obstruction is not ruled out even if ultrasonographic examination
appears normal. Dilated intra-hepatic ducts may appear like a “shotgun sign” or “too many tubes”
clustered around portal vessels. Choleliths may be located in the dependent portion of the gallbladder,
with distal acoustic shadowing. This can be maximized by placing the stone in the focal zone.
Choledocholiths are located in the intra-hepatic biliary tracts. Differentials for distal shadowing structures
imaged in the liver include fibrosis, dystrophic calcification, foreign bodies and gas. Thickening of the
wall of the gall bladder is non-specific and may be present in hepatitis, cholecystitis, right heart failure,
septic conditions and neoplasia. In acute inflammatory diseases, thickening may be due to edema.
Permanent thickening is due to fibrosis. There may be a small amount of free fluid around the gall bladder
that may mimic wall thickening. Sessile or polypoid lesions caused by mucous gland hyperplasia or
adenocarcinomas may be visible. Hepatic veins may enlarge with right heart failure. Thrombosis due to
sepsis, acute hepatitis, or post adrenal surgery may be seen in the portal vein. Chronic liver disease may
lead to acquired postosystemic shunting.

Spleen
The normal, healthy spleen in ferrets may vary in size with the administration of any anesthetic agent. It
will return to pre-anesthetic size within 10-20 minutes of cessation of the agent. Occasionally this may be
evident as increased vasculature or dilation of vessels within the spleen during anesthesia. The
parenchyma will appear homogeneous. The spleen is located caudal to the stomach with the tail laying
 17

along the left body wall. The splenic hilus has hyperechoic fat, that may show distal shadowing. The
spleen is significantly more echogenic than the liver and left kidney. Extramedullary hematopoesis may
be present in spleens, causing splenomegaly.4 Diffuse splenomegaly may be caused by congestion imaged
as hypoechoic. This may occur in toxic conditions or hemolytic anemias. Acute inflammatory diseases
may cause hypoechogenicity while chronic granulomatous disease may appear as hyperechoic.
Neoplasias usually manifest as hypoechoic such as is seen in lymphoma or lymphosarcomas. Hematomas
are fairly common and appear as focal, well-demarcated, hypoechoic areas. Infarcts may be associated
with septicemia and seen at the periphery of the spleen. These will cause indentation of the splenic
capsule. If a “dirty” distal shadow is seen, it may be gas present. Abscesses may image as described in the
liver section. Nodular hyperplasia usually increases echogenicity. Neoplasias diagnosed in splenic tissue
include sarcomas, lymphoma, and less commonly, hemangiosarcoma.

Pancreas
Upper GI radiographic series may be more definitive than ultrasound for pancreatic disease, and to show
duodenal fixation or displacement, increased width of the cranial duodenal flexure, and thickening and/or
deformity of the adjacent duodenum or stomach. Lack of findings on ultrasound exam of the pancreatic
region does not exclude pancreatic disease. The pancreas in the ferret is a “C” shaped structure. The right
limb shows as a hypoechoic structure dorsal or dorsomedial to the descending duodenum, the right of the
portal vein, and superficial to the right kidney. The body lies superficial to the portal vein in the cranial
duodenal flexure. The left limb is immediately caudal to the greater curvature of the stomach.

Pancreatic Disease
Acute pancreatitis may cause signs of biliary obstruction (CBD and gall bladder dilation). The
parenchyma may appear hypoechoic due to edema, hemorrhage, or necrosis. There may be focal
peritonitis imaged as a hyperechoic mesentery and focal free fluid. Duodenal and gastric ileus may be
secondary. Chronic pancreatitis may result in dilated bile ducts. Scarring or calcification will cause
acoustic shadowing. Pancreatitis cannot be differentiated from pancreatic neoplasia or focal septic
peritonitis using ultrasound. Cysts in the pancreas may result from pancreatitis. Abscesses are uncommon.
Islet cell tumors (insulinomas) are common. Then pancreas usually appears ultronographically normal.
The tumors appear as hypoechoic nodules. There may metastasis to the regional lymph nodes, adjacent
duodenal walls, bile duct and into the liver. The tumor may progress to islet cell adenocarinoma that may
have metastasized prior to the appearance of clinical signs. Carcinomatosis or bile duct obstruction may
occur.

Kidneys
The kidneys are often used as landmarks for locating the adrenal glands in ferrets as they are easy to
palpate and image. The renal sinus is the bright, central echo complex. The renal medulla is the
hypoechoic region surrounding the pelvis. The renal cortex is the outer zone of intermediate echogenicity.
Good distinction should be seen between the cortex and medulla. The renal pelvis may dilate with
intravenous fluids or during excretory urography. The right kidney lies on the caudate lover of the liver.
Normal ferret kidneys are between 2.4 and 3 cm.1

Renal Disease
Increased cortical echogenicity may be seen with lymphoma, glomerulonephritis and interstitial nephritis.
Renal cysts are fairly common and may be present within the renal capsule without distention, or may
distort the capsule. Renal cysts can become large and exert a mass effect on surrounding organs that may
make the ferret uncomfortable. Ultrasound-guided drainage of the large cysts is a fairly common
procedure. Care must be taken to use aseptic technique as well as good analgesia. Rarely is kidney
function impaired. They are considered congenital and may be single or multiple. If renal cysts are found,
examination of the pancreas and liver is recommended to screen for additional cysts. Drainage of these is
done if the location is causing discomfort for the ferret. Acquired cysts may sequellae of chronic
 18

nephropathies. Masses identified in ferret kidneys include hematomas, granulomas, abscesses, acute
infarcts, hemangiosarcomas. Solid masses may be associated with lymphomas and rare renal carcinoma.
Infarcts may appear as wedge-shaped hyperechoic areas narrowing at the corticomedullary junction.
There may be aberrant vasculature surrounding the infarct. The renal pelvis may dilate with
pyelonephritis or obstruction to outflow seen with prostatic enlargement due to adrenal disease in male
ferrets. It is less common to see masses, stones, ureteral strictures although hydroureter and
hydronephrosis due to ureteral ligation during ovariohysterectomy have been noted.1 Dilation may also
occur with diuresis. Perinephric pseudocysts have been documented in ferrets.9 There is a large
accumulation of fluid around one or both kidneys in a sub- or extra-capsular location. The fluid is a
transudate and may be urine. A biopsy of the kidney at the time of capsulectomy is recommended if the
fluid is not urine.

Urinary Bladder and Urethra

The bladder wall consists of three layers, and has an apex, body, neck, and trigone regions. The ureteral
papillae are visible in the dorsal trigone. Urine ejection into the bladder is easily visualized. Struvite
crystalluria and/or calculi are not uncommon. Calculi cause shadowing and are usually gravity dependent.
Cystitis results in bladder wall thickening, with most severe lesions occurring in the cranioventral bladder.
It may be seen in conjunction with crystalluria. Changes in the bladder wall may also occur secondarily to
chronic dilation and atony associated with prostatic enlargement and abscesses. Blood clots are irregularly
shaped and gravity dependent. TCC is usually sessile and based in the trigone. It may also occur in the
urethra. Cysts, diverticula, and abscesses have also been seen along the cranioventral apex of the bladder,
associated with the remnant urachus.

Adrenal Glands
The ferret adrenal glands are frequently the focus of abdominal ultrasonography. They are generally
located craniomedial to each kidney. The right adrenal is located between the medial aspect of the cranial
pole of the right kidney and the caudal vena cava. It is immediately cranial to the original of the cranial
mesenteric artery. It may have direct communication with the cvc or have distinct vasculature. It tends to
have its longest axis lying transversely. In the male, it may be to up 4.8 mm in width. In females, 4.1 mm
in width. 5 When enlarged, it may cause distortion or compression of the vena cava and displace the right
kidney laterally and caudally. The left adrenal usually lies superficially and laterally to the aorta between
the cranial mesenteric artery and the left renal artery, at the level of the cranial pole of the kidney. It is
somewhat oval in shape, although it may normally have a more globular appearance and is well
surrounded by fat. Vasculature to the left adrenal may arise from the vena cava or occasionally from the
renal vessels. The phrenicoabdominal artery (dorsal) and vein (ventral) pass obliquely over the center of
left adrenal gland. The gland is closely associated with the renal artery. In males it may be up to 4.4 mm
in width and in females, up to 4.3 mm in width. 5 The glands normally have hypoechoic cortex and
hyperechoic medullary regions. There may be accessory adrenal tissue is retroperitoneal space and
elsewhere in the abdomen. In one study, 38% of ferrets had accessory adrenal tissue. 7

Adrenal Gland Neoplasia

Adrenal cortical tumors have been reported as adenomas and adenocarcinomas.4 While some studies
report most occur on the left, more recent studies show that both are usually affected. They may be
enlarged in thickness, and/or nodules may be present. The diseased gland appears hypoechoic compared
to normal tissue. Other pathology may be found including prostatomegaly, prostatic cysts, uterine stump
pyometra, enlarged preputial tissues, prominent vulva, mammary glands, etc. The adrenal glands are
producing sex steroids that are responsible for the additional clinical findings. 7 Additional neoplasias
including islet cell tumors may also be present. Leiomyosarcoma has been frequently found in enlarged
adrenals. Metastasis can occur including invasion of the caudal vena cava and surrounding tissues. Mass
affects may also account for abdominal pain and other signs of ill health seen in many ferrets. Cortical
 19

hyperplasia while resulting in some gland enlargement may appear ultrasonographically as normal tissue.
Medullary tumors have been documented as pheochromocytoma. 2

Gastrointestinal Tract
The stomach and small bowel have five visible layers: the mucosal surface, the mucosa, sub-mucosa,
muscularis and serosa. The normal wall thickness is less then 3 mm in width. The colon has 3 visible
layers with diffuse gas shadowing. The lymph node at the root of the mesentery is visible and is usually
approximately 12 mm X 7 mm. 8

Gastrointestinal Disease (GI)

GI disease is common in ferrets. Gastric ulcers may be present due to gastritis caused by inflammatory
bowel disease (IBD), helicobacter, and foreign bodies.3 There may be localized gastric wall thickening
with or without an ulcer crater visualized. The gastric lymph node may be enlarged, with gi disease,
lymphoma, and IBD. It is located in the fat near the lesser curvature of the stomach.

Ileus is defined as a luminal distention of the bowel. Segmental dilation may be present in acute cases.
Generalized dilations occur in chronic disease. Foreign bodies are frequently involved in the ferret. Balls
or toy pieces may have smooth margins and cast a distal shadow. Linear foreign bodies product plication
of the small intestines. Secondary intussusception may occur. On transverse view it appears as a
multilayered series of concentric rings. Trichobezoars are common. They may be functional or non-
functional (sub-clinical or asymptomatic). Generalized dilation and obstruction may be viewed. Infectious
diseases such as bacterial enteritis, enterotoxemia or corona virus, anesthesia or intra-surgery
manipulation are also causes of ileus. Neoplasia may also be involved – either within the gi tract or due to
mass effect and compression from without.

Infiltrative disease is frequently the result of a neoplastic process with lymphoma the most common. In
the stomach, there may be uniform hypoechoic thickening. The small intestines may show diffuse
thickening or mass-like structures similar to those seen with adenocarcinoma. It is not possible to
diagnose the type of neoplasia with ultrasound. In adenocarcinomas, the walls may appear more
asymmetric and lacking normal wall layers. The mesentery may appear hyperechoic. There may be focal
atony. Intussussception may be found as the normal proximal bowel “over-rides” the abnormal bowel
section. Inflammatory disease is commonly diagnosed in ferrets, although ultrasound is not specifically a
diagnostic tool. Symmetric wall thickening with retained wall layering may be seen throughout the gi
tract. 3,6

Genital System
The prostate in the ferret is almond-shaped, symmetric, and hypoechoic in neutered males. It is located at
the neck of the bladder just at the pelvic brim. The uterus is a tubular structure that is easily differentiated
from intestines since it lacks both luminal gas and peristalsis. The uterine horns will vary in size
depending on seasonality and stage of the reproductive cycle.

Genital System Disease

The prostate may be a major problem in males with adrenal disease due to prostatic hypertrophy,
prostatitis and prostatic cyst formation. It may become large, hyperechoic, and sometimes heterogenous
with cysts, abscesses, and necrosis. It may appear symmnetrical or asymmetrical. The bladder may be
enlarged due to obstruction. Treatment of adrenal disease will decrease prostatic tissue, although
abscesses and some cysts may persist if sufficient fibrosis has occurred around the lesions. Ultrasound
guided drainage of the larger cysts may differentiate abscess vs transudate. Stump pyometra is not
uncommon in spayed females with adrenal disease if sufficient uterine tissue remains. Cystic endometrial
hyperplasia and neoplasia may appear as a mass between the colon and bladder. A granuloma may form
 20

after ovariohysterectomy at the site of the ovary that appears as a complex mass caudal to the kidney.
Ovarian remnant may appear similarly, or as a nodular, cystic structure.

References
1. Antinoff N, Urinary Disorders in Ferrets, Seminars in Avian and Exotic Pet Medicine 1998: 7: 89-92
2. Besso JG, Tidwell AS, Gliatto JM, Vet Radiol Ultrasound 2000: 41: 345-352
3. Burgess ME, Gastrointestinal and Hepatic Diseases in the Ferret, Proceedings Management of the
Ferret for Veterinary Professionals, 2005: 4: 45-67
4. Neuwirth L, Isaza R, Bellah J, Ackerman N, Collins B, Adrenal Neoplasia in Seven Ferrets, Vet
Radiol Ultrasound 1993: 34: 340-346
5. Neuwirth L, Collins B, Calderwood-Mays M, Adrenal Ultrasonography Correlated with
Histopathology in Ferrets, Vet Radiol Ultrasound 1997: 38: 69-74
6. Nyland TG, Mattoon JS, Veterinary Diagnostic Ultrasound, 1st edition, WB Saunders Co., 1995
7. O’Brien RT, Paul-Murphy J, Dubielzig RB, Ultrasonography of Adrenal Glands in Normal Ferrets,
Vet Radiol Ultrasound 1996: 37: 445-448
8. Paul-Murphy J, O’Brien RT, Spaeth A, Sullivan L, Dubielzig RR, Vet Radiol Ultrasound 1999: 40:
308-310
9. Puerto DA, Walker LM, Saunders HM, Bilateral Perinephric Pseudocysts and Polycystic Kidneys in a
Ferret, Vet Radiol Ultrasound 1998: 39: 309-312
10. Redrobe S, Imaging Techniques in Small Mammals, Seminars in Avian and Exotic Pet Medicine
2001: 10: 187-197

Adapted from SESSION II: INTRODUCTION TO FERRET ULTRASOUND6 October 6, 2006,

Michelle H. Fabiani, DVM, DIPL ACVR
By Cathy A. Johnson-Delaney, DVM, DIPL ABVP for AEMV 2008

Introduction to Computed Tomography (CT) in Exotic Companion Mammals

CT of Exotic Companion Mammals
Vittorio Capello, DVM

Spiral CT scan for exotic patients is a new discipline, and few references are available. Most difficulties
are related to size and diverse anatomical differences of smaller exotic patients. A digital image of a
smaller subject is, by necessity, a lower-resolution image. A smaller picture contains a small number of
pixels; zooming in to increase the size ultimately results in loss of resolution. Soft tissue to hard tissue
ratio is less in smaller species, which results in a narrower grey scale. Even with these limitations,
however, very good images can be obtained with the latest generation of CT machines.

Most recent improvements in CT scans include reduction of scan time, and improved image resolution,
factors that make such scans feasible and useful even for small exotic patients.
Acquisition of the scan is the first step in utilization of this modality; elaboration and manipulation of the
image has vastly improved usefulness. The computer can reduce the thickness of the acquired slices, and
images can be reformatted into two-dimensional multiplanar images and virtual reconstruction of 3D
volume and surface images. Newer CT scans acquire images via the standardized, internationally
recognized DICOM software system, which allows a greater number of visual options. Scanners come
with their own software; however, a free web-based software allows anyone to view and manipulate
DICOM images. OsiriX is a Macintosh program created by Antoine Rosset, from the Department of
Radiology , University of Los Angeles (www.osirix-viewer.com)
 21

Sedation or anesthesia are required for proper positioning for CT, and to reduce breathing movement
artifact, despite the fact that scanning time can be very brief. The patient is most commonly positioned in
ventral recumbency, with the head elevated slightly.
Standard scanning plane angles have been established for some canine breeds, but there are no standards
for exotic animals. Preliminary studies by the authors are currently focused on the anatomy of the normal
and pathologic skull and teeth of rabbits, guinea pigs, and chinchillas. Scanning planes for the skull are
perpendicular to the palatine bone, but further studies may suggest additional advantageous angles, in
particular for the study of the mandible and cheek teeth.

References and Useful Resources:

DICOM viewer for Macintosh:

www.osirix-viewer.com

DICOM viewer for Windows:

www.k-pacs.net

Ultrasound Laboratory Notes

Cathy Johnson-Delaney, DVM, Dipl. ABVP (Avian)

Table 1. Ultrasonography Uses in Small Mammals

Ferret Rabbit Guinea Pig, Rat Mouse,

Chinchilla Hamster,
Gerbil
Echocardiography Echocardiography Echocardiography Echocardiography Echocardiography
Prostate Bladder Ovarian cysts Bladder Bladder
Kidneys, cysts Kidneys Reproductive tract Kidneys Kidneys
Adrenals Liver Kidneys Liver Liver
Liver Gallbladder, bile duct Liver Gallbladder, bile duct Reproductive
Gallbladder, bile duct Reproductive tract, Peritoneal fluid Reproductive tract, tract, cysts
Lymph nodes, IBD, cysts Pleural effusion cysts Peritoneal fluid
lymphadenopathy Peritoneal fluid Masses Peritoneal fluid Pleural effusion
Bladder Pleural effusion Guided biopsies, Pleural effusion Masses
Reproductive tract Masses aspirations Masses Guided
(intact ferret) Guided biopsies, Guided cystocentesis cystocentesis,
Masses aspirations aspirations
Pleural, peritoneal
fluid
Guided biopsies,
aspirations

Formally, terms that are used to describe the appearance of ultrasound images relate to a tissue’s echo
intensity, attenuation, and image texture. Areas of high echo intensity: echogenic, hyperechoic, high echo
intensity or echo-rich. Areas of low echo intensity may be properly termed echo-poor or hypoechoice,
whereas areas with no echoes are said to be anechoic or “echo-free”. As urine and bile are the most
anechoic, it is useful to use the bladder to adjust the screen to establish the baseline “black”. The liver and
spleen are normally in the mid-range of echogenicity, and can be used to set the screen’s contrast and
brightness. Focus depth of the scan will depend on which organ you are imaging, and may need to be
changed during the examination.

Air, Hair: cause many problems, artifacts, inability to image. This includes gas within the
intestinal tract.
 22

Bone, calcifications may interfere with imaging particularly if the tissue to be examined is behind
the bone or calcified material (such as a bladder stone). Ribs interfere with lateral scans of the
heart, but once identified, the ultrasonographer can determine which images are artifact, and
obtain diagnostic images.

Table 2. Densities
Order of Increasing Echogenicity:
Urine, Bile
Renal Medulla
Muscle
Renal Cortex
Liver
Storage Fat
Spleen
Prostate
Renal sinus
Structural fat, vessel walls
Bone, gas, organ boundaries
From Nyland TG, Mattoon JS, Veterinary Diagnostic Ultrasound, WB Saunders Co., Philadelphia, 1995

Laboratory Exercise: Ferret

Patient Preparation:
1. Shave the ferret from pubic bone the xiphoid process. If cardiac scanning, shave the right area of
the chest from the midline laterally approximately half the distance to the spine.
2. The ferret may be restrained on its back, and distracted with a treat.
3. Apply acoustic gel to the mid-abdomen. Begin the scan at the bladder to set the image. If the
ferret is cooperative, the entire examination may be done without sedation.
Scan:
1. Longitudinal plane: palpate the left kidney. Locate with the beam. Move medially at the level of
the kidney and identify the caudal vena cava. Move laterally back to the kidney, and position the
beam so that you are at the anterior pole of the kidney. Move slowly medially. The left adrenal
gland is in the area between the anterior left kidney and the caudal vena cava. It is usually at the
depth of the renal vessels.
2. Transverse scan at the same level. Use the kidney and cvc to locate the area of the left adrenal.
The abdominal aorta will also be visible in cross-section.
a. Note: if the spleen is enlarged, it may overlay much of the kidney and area of the left
adrenal. Use the spleen as an imaging window. You can also do an examination of the
spleen itself.
3. Longitudinal plane: palpate the right kidney. Locate with the beam. Move medially at the level of
the kidney and identify the caudal vena cava. At the cranial pole of the right kidney there is
usually liver overlapping the area where the right adrenal gland is located. The right adrenal lays
on the dorsal surface of the caudal vena cava, at the anterior pole of the kidney, and in the fat
between the kidney and the cvc. It may have separate vasculature. Occasionally it will wrap
around the cvc, and if enlarged, it may cause constriction of the cvc. It may also be on the left of
the cvc, and if enlarged, push against the pyloric area of the stomach/duodenum.
4. Transverse scan at the same level. Use the kidney, cvc, and liver to locate the area of the right
adrenal. The duodenum/pylorus and pancreas may be over lying the adrenal area. You can
differentiate the gi tract by the motility (particularly if the ferret is awake and swallowing
Nutrical).
 23

a. Just anterior to the area of the right adrenal will be the gallbladder, and the portal vein,
although the portal vein is easier to locate on a longitudinal scan of the liver.
b. If your picture is mostly liver, you are too anterior. Use the region between the anterior
pole of the right kidney and the gallbladder to find the location of the adrenal tissue.
5. Longitudinal scan of liver: locate the gallbladder and portal vein. Note path of the portal vein, and
relative diameters of bile ducts, major vessels. Dilation of vessels in the liver is often seen with
heart disease in the ferret. The liver may look almost “cystic” in severe cases of congestion.
6. Transverse scan of the liver: locate the gallbladder, portal vein.
7. Apical examination of the heart: using the liver as a window, the heart can be scanned. This is
done from just right of the midline, approximating the right parasternal short axis view. Note
movement, contractility, proportion of walls, pericardial condition. For full cardiac examination,
the chest will need to be shaved primarily from the midline right to about ½ distance to the spine
(rib cage), and gel applied. The most useful scan then is done as a right parasternal long axis 4
chamber view. M-mode can also be done, following the same parameters as used for dogs and
cats.
8. Bladder and prostate. Start with a longitudinal scan to image relative position of bladder and
position of the urethra. The prostate lies at the pelvic brim and will appear as a dense mass. If
enlarged, there will be urethral constriction, change in angle/positioning of the bladder, and some
bowel displacement. Switch to transverse scanning to image the diameter of the urethra in cross
section.
9. Spleen: Scan longitudinally, then transversely. Look for dilated vessels, changes in densities.
Normally the spleen appears fairly homogeneous. Note that it will always be enlarged with any
sedative or anesthesia. Absolute size and architecture is best examined without
sedation/anesthesia.
10. GI tract: Ingesta within the gi tract can cause artifacts. Gas, hair, obstructions, formed fecal
material in the large bowel can be visualized particularly in contrast to liquid/nutrical moving
through the stomach into the intestine. Intestinal walls of individual bowel loops can be
visualized particularly if there is significant body fat.
If the ferret is cooperative or sedated, manual manipulation of the kidneys and other organs can also
be done to isolate suspected masses and tissues seen in the scan. This is helpful to locate
circumscribed masses and determine possible tissue of origin.

Laboratory Exercise: Rabbit

Thoracic/Cardiac Imaging:
Fur may need to be clipped on the lateral chest wall, both right and left sides to access the heart. The
patch should be roughly a rectangle, approximately 2-3 cm in size. The rabbit may be held or laid on the
table slightly rotated on the side opposite of the side to be accessed. Apply ultrasound gel and begin
imaging.

Abdominal Imaging:
Kidneys: May be imaged from lateral paralumbar area rather than from the ventral abdomen. Palpate the
kidneys and if necessary clip an area of hair over each kidney. Alternatively, in some rabbits the hair can
be sufficiently parted and wetted with ultrasound gel to obtain a satisfactory image. Rabbits can usually
sit in a normal position for this technique.

For liver, bladder, reproductive organs, the rabbit needs to be scruffed and held upright with the
abdomen facing the ultrasonographer or in some pet rabbits or if sedated, the rabbit may be laid in
dorsal recumbancy.

To image the liver, shave a small area just caudal to the right ribcage.
 24

To image the bladder, shaving is usually not necessary. The bladder will lay just cranial to the
pubic brim. The rabbit can also lay on its side for bladder imaging. If the bladder is full of
calcium sludge, there will be a lot of artefact, although the walls can still be evaluated.

Other organs: will depend on the volume of ingesta and gas within the gastrointestinal tract. Imaging can
be attempted of the stomach, adrenals, and female reproductive tract (if present).

Intact females: image the bladder first and adjust contrast. The uterus/uterine horns are positioned just
dorsal to the bladder, with the horns extending laterally to the ovaries. The ovaries will lay just cranial to
a full bladder. If the cecum and colon are distended with ingesta, these may be difficult to find. In the
young female, the organs will lie closer to the bladder and may be easier to find.

QUESTIONS AND NOTES