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Vol. 24, No. 8 August 2002 Comments? Questions? Email: compendium@medimedia.com Web: VetLearn.com Fax: 800-556-3288

CE

Article #4 (1.5 contact hours)

Refereed Peer Review

Diagnostic Imaging of Dogs with Suspected Portosystemic Shunting

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

Christopher R. Lamb, MA, VetMB, MRCVS, DACVR, DECVDI

University of Tennessee

Gregory B. Daniel, DVM, MS, DACVR

ABSTRACT: Contrast radiography, ultrasonography, and scintigraphy may all be used in the diagnostic workup of dogs suspected of having portosystemic shunting (PSS). Contrast radiography (portal venography), although invasive, is the definitive method for demonstrating shunts in any anatomic site. Ultrasonography is a convenient, noninvasive method for diagnosing congenital PSS, determining shunt morphology, and assessing other abdominal structures. Doppler ultrasonography is a more demanding technique that may be used to look for signs of portal hypertension and acquired PSS. Scintigraphy is a useful alternative noninvasive technique for diagnosing all types of PSS and is a method for measuring the proportion of portal blood that bypasses the liver. There appears to be limited potential for prognosis based on any of these imaging modalities.

ortosystemic shunting (PSS) is a well-recognized condition in dogs that causes a variety of clinical signs, including stunted growth, polyuria and polydipsia, vomiting, ataxia, seizures, and altered behavior.1 PSS may be classified as primary or secondary. Primary (congenital) PSS occurs as a single (or occasionally double) macroscopic vascular connection between the portal vein or a portal tributary and the caudal vena cava or other systemic vein. Congenital PSS may be divided anatomically into intrahepatic and extrahepatic forms.2 Intrahepatic PSS, which occurs mainly in large-breed dogs, is described according to its position in the liver as left-, central-, or right-divisional3 (Figure 1). The morphology of left-divisional shunts is compatible with patent ductus venosus. Irish wolfhounds are predisposed to patent ductus venosus, whereas Old English sheepdogs, golden and Labrador retrievers, and Australian cattle dogs are predisposed to central-divisional shunts.25 Extrahepatic PSS usually connects a major tributary of the portal vein, such as the splenic or gastric vein, with the caudal vena cava (Figure 1). Occasionally, the shunting vessel drains into the azygos vein. Congenital extrahepatic PSS usually affects small breeds, particularly terriers, miniature schnauzers, miniature poodles, shih tzus, and Lhasa apsos.1,4

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Central

Left Right

CVC

PV

CVC

PV

Figure 1ANormal anatomy

Figure 1BLeft-divisional shunt

Figure 1CCentral-divisional shunt

Shunt PV CVC

Multiple shunts

CVC

CVC

Figure 1DRight-divisional shunt

Figure 1ECongenital extrahepatic shunt

Figure 1FAcquired extrahepatic shunt

Figure 1Anatomy of the liver and types of portosystemic shunts. (A) Hepatic divisions, lobes, and normal pattern of branching of

the portal vein (PV, caudal aspect; C = caudate lobe; LL = left lateral lobe; LM = left medial lobe; P = papillary process of caudate lobe; Q = quadrate lobe; RM = right medial lobe; RL = right lateral lobe). (B) Left-divisional shunt. This arises from a left branch of the PV and drains into the left hepatic vein (LHV) via the patent ductus venosus (arrow). The confluence of ductus and LHV is usually dilated and is known as the ampulla (A; CVC = caudal vena cava). (C) Central-divisional shunt. The PV has a relatively straight course into the right medial lobe, where it forms a localized dilation on the ventral aspect of the CVC. The communication between the PV and the CVC is via a foramen (arrow). (D) Right-divisional shunt. The shunting vessel passes within the right lateral or caudate lobe, sometimes forming a wide loop before draining into the CVC. (E) Congenital extrahepatic PSS. A single anomalous vessel connects portal tributaries with the CVC. Arrows indicate direction of blood flow. (F) Acquired extrahepatic PSS. This often develops secondary to hepatic disease that inhibits blood flow through the liver. Portal tributaries may be dilated. Flow in the portal vein may be hepatofugal (dashed arrow). (A through D were redrawn from Lamb CR: Ultrasonography of portosystemic shunts in dogs and cats. Vet Clin North Am Small Anim Pract 28:725753, 1998; with permission).

Secondary (acquired) PSS takes the form of multiple, small extrahepatic vessels in the omentum or retroperitoneum near the kidneys, which drain directly or indirectly into the caudal vena cava2,6 (Figure 1). Acquired PSS develops in response to chronic portal hypertension, which occurs most often as a result of hepatic fibrosis or cirrhosis.6,7 Breed-associated hepatopathies may lead to portal hypertension and acquired PSS in German shepherds, American cocker spaniels, Doberman pinschers, and Labrador retrievers.6 Portal hypertension may also occur in young dogs secondary to congenital anomalies, such as portal vein atresia8 or hepatic arterioportal fistula.9

ROLE OF DIAGNOSTIC IMAGING The role of diagnostic imaging in dogs with signs of PSS is to determine whether PSS is present, to determine whether the lesion is congenital or acquired, and to assess the severity of the shunting. Also, diagnostic imaging enables preoperative morphologic assessment of intrahepatic PSS. This is useful because the morphology largely dictates which techniques may be used for surgical treatment, thereby possibly reducing surgical time. Complications occur commonly during surgical treatment of dogs with intrahepatic shunts, particularly if surgery is prolonged because the shunt is difficult to find.4,10

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Table 1. Comparison of Imaging Techniques for Detecting Features of Portosystemic Shunts in Dogs Feature Reduced hepatic volume Anomalous vessel Intra- versus extrahepatic location Portal hypertension Shunt fraction Renal enlargement Urate urolithiasis Survey Radiography + Portal Venography ++ +++ +++ +++ + + Ultrasonography ++ ++ +++ ++ + ++ ++ Scintigraphy ++ + + +++ +

+ = Limited information; ++ = useful information; +++ = detailed information, accurate assessment often possible.

The diagnostic imaging techniques reported most frequently in relation to PSS in small animals are portal venography, ultrasonography, and scintigraphy. Radiography and ultrasonography provide information principally about the structural abnormalities in dogs with PSS, whereas scintigraphy enables assessment of abnormal blood flow. Each of these imaging modalities has different strengths and weaknesses (Table 1).

Radiography Survey radiography of the liver enables a limited eval-

uation of its position, size, shape, and opacity.11 The size of the liver is usually inferred from the appearance of its caudoventral border as seen on a lateral radiograph and from the position of the stomach or spleen, which may be displaced cranially when the liver is small. A small liver usually has a blunt caudal border that lies within the costal arch (Figure 2). In dogs, hepatic volume is usually determined based on a subjective assessment. There is a fair correlation between linear dimensions of the liver and its volume,12 but attempts to estimate hepatic volume from abdominal radiographs of dogs have proved imprecise.

Figure 2Reduced hepatic volume as seen in a lateral abdom-

inal radiograph. The caudal border of the liver is flattened and lies within the costal arch (arrow). (St = stomach; Sp = spleen.)

Contrast Radiography Portal venography, although invasive, is the definitive method for demonstrating shunts in any anatomic site. Various techniques for injecting contrast medium into the portal vein have been described, including operative mesenteric portography, cranial mesenteric angiography, and percutaneous splenoportography.1317 Portal venography is the optimal method for assessing shunt location (intra- versus extrahepatic) and morphology.3,16,17 Operative mesenteric portography, although invasive, is a relatively simple and direct technique. It involves taking radiographs immediately after injecting contrast medium into a catheter placed surgically in a jejunal vein; therefore, it is necessary either to have a radiography room that is clean enough for abdominal surgery or to use mobile radiographic equipment in surgery. This technique produces good opacification of the portal vein and usually enables PSS to be readily detected13,14 (Figure 3). It is frequently used in combination with surgery to treat congenital PSS, and the same jejunal vein catheter is used to measure portal blood pressure during shunt attenuation. Alternatively, selective catheterization of the cranial mesenteric artery via a femoral arteriotomy and injection of contrast medium opacifies the portal vein after circulation through the intestinal vessels.1315 This technique is used less often than operative mesenteric por-

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Figure 3ANormal anatomy

tography because it is technically more demanding (requiring image intensification during catheter placement) and, if a congenital shunt is detected or a liver biopsy is required, a laparotomy is indicated anyway. It is typical to repeat the intraoperative portal venogram immediately after ligation of a shunt. This serves two purposes: It helps confirm that the correct vessel has been ligated (i.e., there is no second shunt), and it enables assessment of the intrahepatic portal vasculature (Figure 4). Poor opacification of the lobar portal branches on a postligation portal venogram might occur if they were small or nonpatent and would suggest hypoplasia of the portal vessels. However, the appearance of portal branches in the postligation portal venogram does not help predict whether the patients condition will be improved after surgery.18 Of 26 dogs that had very poor opacification of hepatic branches after shunt attenuation in a recent study, only 5 had a poor outcome and 21 did well.18

Figure 3BCongenital extrahepatic PSS

Figure 3CAcquired extrahepatic PSS Figure 3Examples of operative mesenteric portal venogra-

phy (ventrodorsal view). (A) Normal opacification of hepatic portal branches following injection of contrast medium into a portal tributary (curved arrow). There is retrograde flow into the splenic veins (S). (B) Congenital extrahepatic PSS. An anomalous curved vessel (straight black arrow) drains into the caudal vena cava (white arrows). There is virtually no opacification of hepatic portal veins. (C) Acquired extrahepatic PSS. Multiple tortuous vessels (black arrow) drain into the caudal vena cava (white arrows). The hepatic portal veins are attenuated.

Ultrasonography Two-Dimensional Gray-Scale Ultrasonography Ultrasonography is a rapid, convenient, noninvasive method for assessing PSS and a versatile imaging modality, enabling visualization of most congenital PSS and lesions affecting other abdominal structures as well as estimation of hepatic volume and vascularity (Table 2).9 In dogs with congenital PSS, the liver is usually small and the caliber and number of visible intrahepatic vessels are reduced.9,19,20 Hepatic volume may be estimated ultrasonographically by measuring the maximal distance from the caudal tip of the liver to the diaphragm. 21 There is a roughly linear relationship between this dimension and body weight; however, for a dog of any particular body weight, there is quite a wide normal range21; hence confident conclusions are possible only when examining a dog with either a very small or very large liver. As for radiography, subjective evaluation of hepatic volume is also based on the position of the stomach or spleen and the shape of the caudal hepatic border, which usually appears blunted in ultrasonographic images of dogs with small livers. The ability to examine large blood vessels makes ultrasonography a useful diagnostic test for congenital PSS in dogs.9,19,20,22 Ultrasonography has a greater than 90% accuracy rate for diagnosing congenital PSS.20 It is also possible to differentiate whether the shunt is intrahepatic or extrahepatic in nearly all affected dogs. Intrahepatic shunts appear as broad, curved, or tortuous vessels that connect the portal vein and the caudal vena cava. They may be visualized from a ventral window in a small dog, but the most useful approach is via an

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Table 2. Typical Ultrasonographic Findings in Dogs with Portosystemic Shunting Parameter Hepatic volume Hepatic parenchyma Renal volume Anomalous vessel Portal blood flow velocity Other potential findings Congenital PSS Usually reduced Attenuated vessels or reduced numbers of vessels Often increased Usually single; may be large, intraor extrahepatic May be increased and variable Urinary calculi Variable Diffuse or multifocal echotextural changes Usually normal Multiple, small, extrahepatic Reduced, sometimes hepatofugal Urinary calculi Dilated abdominal veins Portal vein thrombosis Lesion impinging on portal vein Ascites Pancreatic edema Acquired PSS

CVC Site of ligation

Shunt PV PV

affecting the hepatic parenchyma or the portal vein, such as signs of cirrhosis, hepatoportal fistula, or portal vein thrombosis.9,23,24 Other ultrasonographic signs that may be observed in dogs with acquired PSS include congested spleen, peritoneal fluid, pancreatic edema, and urolithiasis (Table 2).9

Doppler Ultrasonography Doppler ultrasonography enables detection and measurement of blood flow in large vessels and has been used to investigate hepatic diseases that may alter portal blood flow (Figure 7).9,25 Normal Figure 4Operative mesenteric portal venogram of a congenital extrahepatic PSS before and after ligation of the shunting vessel. The portal vein (PV) appears portal blood flow is nonpulsatile with a hypoplastic, but there is fair opacification of intrahepatic portal veins (arrow- mean velocity of approximately 15 cm/sec in unsedated dogs.9 Congenital heads; CVC = caudal vena cava). PSS represents a low-resistance path for blood to bypass the liver and enter the caudal vena cava; hence increased and/or variable portal intercostal window, just cranial to the right kidney3,9,20 blood flow is present in many affected dogs. 20 Most (Figure 5). Dogs with extrahepatic congenital PSS typicongenital PSS is detectable using two-dimensional, cally have anomalous vessel that drains into the caudal gray-scale imaging, but occasionally in a dog in which vena cava between the right renal vein and the hepatic the shunting vessel has not been found the diagnosis veins. Because of its dorsal location, most extrahepatic may be based on finding abnormally high, variable porPSS is also visible only when using a right flank or tal blood flow.9,20 Dogs with portal hypertension and intercostal window.9,20 acquired PSS may have reduced or reversed (i.e., Ultrasonographic diagnosis of acquired PSS is more hepatofugal) portal blood flow, and flow in portal tribdifficult because the shunting vessels are usually small utaries (e.g., the splenic vein) may also be reversed.9,25 It and do not occur in such consistent locations as conis worth attempting to measure portal blood flow in genital shunts. They may be observed in the retroperianimals with suspected hepatic insufficiency because toneum near the kidneys or medial to the spleen (Figportal hypertension may be present even if the hepatic ure 6).9 The underlying cause of acquired PSS may be parenchyma appears normal. observed ultrasonographically if there are abnormalities
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Figure 6A Figure 5A

Figure 5B Figure 6B

Figure 5C Figure 6C Figure 5Ultrasonography in dogs with congenital PSS. (A)

Sagittal image showing a small liver (L). The positions of the diaphragm (D), stomach (St), and small intestine (SI) are also visible. (B) Right intercostal image showing a tortuous intrahepatic vessel (arrows); its position and morphology are compatible with a right-divisional shunt. (C) Right intercostal image showing the point at which an extrahepatic PSS (arrow) drains into the caudal vena cava (CVC; Ao = aorta; pv = portal vein).

Figure 6Ultrasonography in dogs with acquired PSS. (A)

Sagittal image showing peritoneal fluid (PF) and a liver with a heterogeneous echotexture and knobby surface (arrows). This combination of signs is typical of cirrhosis. (B) Close-up of the caudal pole of the left kidney (LK) and adjacent retroperitoneum in which several small irregular hypoechoic structures compatible with vessels are visible (arrows; CVC = caudal vena cava). (C) Color-flow Doppler image is positive for flow in these vessels.

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function, not structure, which is in contrast to the images obtained by radiography or ultrasonography. In many diseases, abnormal function precedes any morphologic changes. Scintigraphy has been used in dogs to examine hepatocyte function, 26,27 ow fl excretion of bile,28 reticuloendothelial function of the liver, 29 and portal fl ow blood flow.3033 For portal scintigraphy, a small amount of radioisotope is adminisNormal tered via a per-rectal catheter inserted into the colon, where it is absorbed into the portal system. A variety of radioisotopes are absorbed into the Congenital PSS portal circulation from the colon, 123 I-iodoamphetamine and Figure 7Examples of Doppler spectra obtained from the portal vein. In a normal, including 99m Tc-pertechnetate. 3033 Pertechneunsedated dog (left), portal flow is relatively uniform. Portal hypertension (top right) results in reduced velocity flow (in this instance, to a mean of 5 cm/sec). In dogs tate is the most commonly used radioisotope for portal scintigraphy. with congenital PSS (bottom right), flow may be increased and variable. In a normal animal, the liver receives the radioisotope first via the portal vein, but if there is a PSS, the radioisotope bypasses Scintigraphy the liver and initially reaches the heart (Figure 8). Note Scintigraphy is a noninvasive, quantitative method that the location or type of PSS cannot be determined for imaging normal physiologic processes and dysfuncscintigraphically because of the low spatial resolution tion that may occur as a result of disease. Scintigraphic of the gamma camera. images depict blood flow or metabolism in the body When a series of scintigraphic images are acquired according to the distribution of a radioactive element after administering the radioisotope, the portal vein (radioisotope) linked to a metabolite, which is detected and liver are normally visualized after 10 to 14 secusing a gamma camera. These images principally reflect onds; it then takes another 8 to 14 seconds for the radioisotope to pass through the hepatic sinusoids into Normal PSS the hepatic veins, caudal vena cava, and heart (Figure 9). In a dog with PSS, the radioisotope usually accumulates in the heart before the liver. Quantitative analysis is possible using an imaging computer. Regions of interest (ROIs) are created around the liver and heart, and the accumulation of radioisotope in these ROIs is then measured over time (Figure 9). An estimate of the proportion of portal blood that bypasses the liver (shunt fraction [SF]) can be made by comparing the counts in the liver and heart after the radioactivity has entered the portal venous system Liver Heart Liver Heart using the following formula:
Portal hypertension
Figure 8Scintigraphic images of a normal dog (left) and a dog with congenital PSS (right). Each image represents the distribution of radioisotope after injection into the colon. The majority of radioisotope is in the liver, with some reaching the heart after passing normally through hepatic sinusoids and the caudal vena cava. In the dog with PSS, the liver is barely visible because most of the injected radioisotope has reached the systemic circulation.

Heart counts 012 sec SF = 100% Liver counts + Heart counts

012 sec 012 sec

The SF is normally less than 15%. Most dogs with congenital PSS have an SF greater than 70%.

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An alternative technique for portal scintigraphy involves ultrasound-guided injection of radiochemical directly into a splenic vein.34 This method of injection combined with the use of 99mTc-labeled macroaggregated albumin, which is normally trapped in the hepatic sinusoids, provides scintigraphic images in which any activity in the lung is the result of PSS. Typical values of shunt index using this technique are less than 5% for normal dogs and greater than 90% for dogs with congenital PSS. 34 This wide separation of values suggests that this is a particularly accurate diagnostic test.
Figure 9A

Normal 1400 1200

Counts

1000 800 600 400 200

0 0

Liver Heart

50

100
Time (sec)

150

PSS 1000 800

Counts

600 400 200

0 0

Liver Heart

50

100
Time (sec)

150

Figure 9B Figure 9 Dynamic scintigraphic study. (A) A series of images acquired at 4-second intervals from a normal dog showing uptake of radioisotope into the portal vein (at 4 and 8 seconds) followed by the liver (more than 8 seconds), caudal vena cava, and heart (more than 16 seconds). From such an acquisition, it is possible to produce timeactivity curves. (B) Normal timeactivity curve (top) and that from a dog with congenital PSS (bottom), in which radioisotope accumulates in the heart faster than in the liver.

ASSESSMENT OF PROGNOSIS Although most dogs improve clinically after surgery to treat congenital PSS, some dogs have persistently high serum bile acid concentrations,35 and some have recurrent signs months or years after apparently successful surgery. There have been attempts to use scintigraphy to gain information that can serve as a basis for prognosis. In a recent retrospective study of 126 dogs with PSS, there was no difference in preoperative SF between dogs with congenital and acquired PSS or between dogs with congenital PSS in different anatomic sites.a Furthermore, there was no correlation between preoperative SF and clinicopathologic results, inoperative portal, or final outcome. Therefore, although it is a useful diagnostic test, calculation of SF does not help define the type of shunt or predict the outcome. After surgery to treat congenital PSS, SF falls to less than 30% in most dogs.36,37 In a dog with a congenital PSS that is completely ligated, the postoperative SF will be in the normal range. When using the colonic method of scintigraphy to measure SF following shunt attenuation, the immediate postoperative SF may not be significantly different from the preoperative SF, yet the animal improves clinically. This discrepancy may reflect a lack of precision in SF determinations. There are various technical difficulties with using colonic portal scintigraphy, including a high degree of inter-operator variability, which makes it difficult to compare results from different dogs or repeated measurements on the same dog.38 Despite these difficulties, SF is often measured to monitor the progress of shunt occlusion. In dogs in which it is not possible to fully ligate the shunt (because portal pressures rise too high), attenuation may be achieved using a device called an Ameroid constrictor to gradually attenuate the lumen of the shunting vessel.39,40 In most dogs treated this way, SF is
a Personal communication: Daniel GB, University of Tennessee,

Knoxville, 2002.

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Ameroid constrictor

Multiple acquired shunts

Figure 10Operative portal venogram of a dog that developed multiple PSS as a result of portal hypertension following treatment of a congenital PSS using an ameroid constrictor.

normal within 4 to 8 weeks. Dogs with persistently increased SF 60 days after surgery usually have developed acquired PSS (Figure 10).

REFERENCES
1. Center SA, Magne ML: Historical, physical examination, and clinicopathologic features of portosystemic vascular anomalies in the dog and cat. Semin Vet Med (Surg Small Anim Pract) 5:8393, 1990. 2. Payne JT, Martin RA, Constantinescu GM: The anatomy and embryology of portosystemic shunts in dogs and cats. Semin Vet Med Surg (Small Anim Pract) 5:7682, 1990. 3. Lamb CR, White RN: Morphology of congenital intrahepatic portacaval shunts in dogs and cats. Vet Rec 142:5560, 1998. 4. Tisdall PLC, Hunt GB, Bellenger CR, Malik R: Congenital portosystemic shunts in Maltese and Australian cattle dogs. Aus Vet J 71:174178, 1994. 5. Hunt GB, Bellenger CR, Pearson MRB: Transportal approach for attenuating intrahepatic portosystemic shunts in dogs. Vet Surg 25:300308, 1996. 6. Boothe HW, Howe LM, Edwards JF, Slater MR: Multiple extrahepatic portosystemic shunts in dogs: 30 cases (19811993). JAVMA 208:18491854, 1996. 7. Rutgers HC, Haywood S, Kelly DF: Idiopathic hepatic fibrosis in 15 dogs. Vet Rec 133:115118, 1993. 8. Van den Ingh TSGAM, Rothuizen J, Meyer HP: Portal hypertension associated with primary hypoplasia of the hepatic portal vein in dogs. Vet Rec 137:424427, 1995. 9. Lamb CR: Ultrasonography of portosystemic shunts in dogs and cats. Vet Clin North Am Small Anim Pract 28:725753, 1998. 10. Komtebedde J, Forsyth SF, Breznock EM, Koblik PD: Intrahepatic portosystemic vascular anomaly in the dog: Perioperative management and complications. Vet Surg 20:3742, 1991. 11. Suter PF: Radiographic diagnosis of liver disease in dogs and cats. Vet Clin North Am Small Anim Pract 12:153173, 1982. 12. Van Bree H, Jacobs V, Vandekerckhove P: Radiographic assessment of liver volume in dogs. Am J Vet Res 50:16131615, 1989. 13. Suter PF: Portal vein anomalies in the dog: Their angiographic diagnosis. J Am Vet Radiol Soc 16:8497, 1975. 14. Schmidt S, Suter PF: Angiography of the hepatic and portal venous system in the dog and cat: An investigative method.Vet Radiol 21:5777, 1980.

15. Wrigley RH, Park RD, Konde LJ, Lebel JL: Subtraction portal venography. Vet Radiol 28:208212, 1987. 16. Birchard SJ, Biller DS, Johnson SE: Differentiating intrahepatic versus extrahepatic portosystemic shunts in dogs using positivecontrast portography. JAAHA 25:1317, 1989. 17. Martin RA, Payne JT: Angiographic results of intrahepatic portocaval shunt attenuation in three dogs. Semin Vet Med Surg (Small Anim Pract) 5:134141, 1990. 18. White RN, Burton CA, McEvoy FJ: Surgical treatment of intrahepatic portosystemic shunts in 45 dogs. Vet Rec 142:358365, 1998. 19. Wrigley RH, Konde LJ, Park RD, Lebel JL: Ultrasonographic diagnosis of portacaval shunts in young dogs. JAVMA 191:421424, 1987. 20. Lamb CR: Ultrasonographic diagnosis of congenital portosystemic shunts in dogs: Results of a prospective study. Vet Radiol Ultrasound 37:281288, 1996. 21. Barr F: Normal hepatic measurements in mature dogs. J Small Anim Pract 33:367370, 1992. 22. Holt DE, Schelling C, Saunders HM, Orsher RJ: Correlation of ultrasonographic findings with surgical, portographic, and necropsy findings in dogs and cats with portosystemic shunts: 63 cases (19871993). JAVMA 207:11901193, 1995. 23. Lamb CR, Wrigley RH, Simpson KW, et al: Ultrasonographic diagnosis of portal vein thrombosis in four dogs. Vet Radiol Ultrasound 37:121129, 1996. 24. Van Winkle TJ, Bruce E: Thrombosis of the portal vein in eleven dogs. Vet Pathol 30:2835, 1993. 25. Nyland TG, Fisher PE: Evaluation of experimentally induced canine hepatic cirrhosis using duplex Doppler ultrasound.Vet Radiol 31:189194, 1990. 26. Daniel GB, Bahr A, Dyke J, et al: Hepatic extraction efficiency and excretion rate of 99mTc-mebrofenin in the dog. J Nucl Med 37:18461849, 1996. 27. Daniel GB, Denovo R, Schultze AE, et al: Hepatic extraction efficiency of 99mTc-mebrofenin in the dog with toxic-induced liver disease. J Nucl Med 39:12861292, 1998. 28. Daniel GB, Tucker RL: Liver scintigraphy: Application in small animals. Semin Vet Med Surg (Small Anim Pract) 6:154163, 1991. 29. Koblik PD, Hornof WJ: Technetium 99m sulfur colloid scintigraphy to evaluate reticuloendothelial system function in dogs with portasystemic shunts. J Vet Intern Med 9:374380, 1995. 30. Koblik PD, Yen C, Hornof WJ, et al: Use of transcolonic 123Iiodoamphetamine to diagnose spontaneous portosystemic shunts in 18 dogs. Vet Radiol 30:6773, 1989. 31. Koblik PD, Yen CK, Komtebedde J, Hornof WJ: Comparison of transcolonic 123I-iodoamphetamine and portal vein injection of 99mTc-macroaggregated albumin shunt fraction calculations in experimental dogs with acquired portosystemic shunts. Vet Radiol 31:170174, 1990. 32. Daniel GB, Bright R, Ollis P, Shull R: Per rectal portal scintigraphy using 99mtechnetium pertechnetate to diagnose portosystemic shunts in dogs and cats. J Vet Intern Med 5:2327, 1991. 33. Koblik PD, Hornof WJ: Transcolonic sodium pertechnetate Tc99m scintigraphy for diagnosis of macrovascular portosystemic shunts in dogs, cats, and potbellied pigs: 176 cases (1988 1992). JAVMA 207:729733, 1995. 34. Meyer HP, Rothuizen J, van den Brom WE, et al: Quantitation of portosystemic shunting in dogs by ultrasound-guided injection of 99mTc-macroaggregates into a splenic vein. Res Vet Sci 57:5862, 1994.

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35. Burton CA, White RN: Portovenogram findings in cases of elevated bile acid concentrations following correction of portosystemic shunts. J Small Anim Pract 42:536540, 2001. 36. Van Vechten BJ, Komtebedde J, Koblik PD: Use of transcolonic portal scintigraphy to monitor blood flow and progressive postoperative attenuation of partially ligated single extrahepatic portosystemic shunts in dogs. JAVMA 204:17701774, 1994. 37. Meyer HP, Rothuizen J, van Sluijs FJ, et al: Progressive remission of portosystemic shunting in 23 dogs after partial closure of congenital portosystemic shunts. Vet Rec 144:333337, 1999. 38. Samii VF, Kyles AE, Long CD, et al: Evaluation of interoperator variance in shunt fraction calculation after transcolonic scintigraphy for diagnosis of portosystemic shunts in dogs and cats. JAVMA 218:11161119, 2001. 39. Vogt JC, Krahwinkel DJ, Bright RM, et al: Gradual occlusion of extrahepatic portosystemic shunts in dogs and cats using the Ameroid constrictor. Vet Surg 25:495502, 1996. 40. Murphy ST, Ellison GW, Long M, van Gilder J: A comparison of the ameroid constrictor versus ligation in the surgical management of single extrahepatic portosystemic shunts. JAAHA 37:390396, 2001.

c. Linear measurements of the liver are roughly proportional to body weight. d. all of the above 5. Which statement about ultrasonography of congenital PSS is correct? a. Ultrasonography is less than 50% accurate for diagnosing congenital PSS in dogs. b. Extrahepatic PSS is most readily visualized using a ventral approach. c. It is rarely possible to distinguish intrahepatic versus extrahepatic PSS ultrasonographically. d. Extrahepatic PSS is often visible when it joins the caudal vena cava between the right renal and hepatic veins. 6. Which abnormality is commonly observed during ultrasonography in dogs with congenital PSS? a. small kidneys c. pancreatic edema b. urolithiasis d. portal vein thrombosis 7. Scintigraphy following the administration of 99mTcpertechnetate enables examination of which hepatic function? a. reticuloendothelial cell function b. kinetics of bile flow c. portal blood flow d. hepatocyte metabolism 8. When performing scintigraphy by injection of 99mTclabeled macroaggregated albumin into a splenic vein, normal values for SF in dogs are usually less than _____%. a. 5 c. 30 b. 15 d. 50 9. Preoperative measurement of SF in dogs with suspected PSS usually enables determination of a. intra- versus extrahepatic shunt location. b. congenital versus acquired PSS. c. likelihood of successful surgical treatment. d. presence or absence of PSS. 10. What is the most likely diagnosis in a dog with suspected hepatic insufficiency in which ultrasonography and scintigraphy reveal low-velocity hepatofugal flow in the portal vein and a SF of 50%? a. congenital intrahepatic PSS b. congenital extrahepatic PSS c. acquired extrahepatic PSS d. hepatic disease without significant PSS

ARTICLE #4 CE TEST The article you have read qualifies for 1.5 contact hours of Continuing Education Credit from the Auburn University College of Veterinary Medicine. Choose the best answer to each of the following questions; then mark your answers on the postage-paid envelope inserted in Compendium.

CE

1. Old English sheepdogs and Australian cattle dogs are predisposed to which type of PSS? a. congenital extrahepatic b. congenital intrahepatic c. multiple acquired extrahepatic d. patent ductus venosus 2. Which condition is unlikely to result in portal hypertension? a. hepatic cirrhosis b. hepatic arterioportal fistula c. portal vein atresia d. patent ductus venosus 3. Which contrast radiographic procedure would not be suitable as a means of portal venography? a. operative mesenteric portography b. cranial mesenteric angiography c. celiac angiography d. percutaneous splenoportography 4. Which statement about the canine liver is correct? a. Radiographic evaluation of liver size is usually based on a subjective assessment. b. Linear dimensions of the liver are roughly proportional to its volume.

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