RE: thoracic x ray interpretation

Robin Grimmer — Tue, 22 Sep 2015 17:03:41 GMT

[quote user="Eamon McAllister"]

On this view the heart looks quite spherical so I would consider pericardial effusion as a possible diagnosis.

[/quote]

I see your point but no evidence of right-sided heart failure.

RE: thoracic x ray interpretation

Eamon McAllister — Tue, 22 Sep 2015 16:58:30 GMT

On this view the heart looks quite spherical so I would consider pericardial effusion as a possible diagnosis.

RE: thoracic x ray interpretation

Robin Grimmer — Tue, 22 Sep 2015 09:48:44 GMT

I think the difference in the two views is that the first view (assuming R lateral, but no R/L markers) is expiratory - less movement blur and the second view (assume L lateral) is somewhere in between as much more movement blur. This shows the perils of interpreting pathology that may not be there. The trouble with these sorts of cases where owners limit how much you can do is that you don't get a proper diagnosis, at this stage we're not even sure if it's respiratory or cardiac. So you end up trying empirical treatment that may be ineffective - then you end up repeating rads etc and in the long run probably costs more than if they let you do a proper job in the first place!

RE: thoracic x ray interpretation

ruths — Tue, 22 Sep 2015 08:20:59 GMT

I have seen a number of staffies with PIE that have an alveolar pattern at the extreme end.

but yes, I agree that the second image is remarkably different. How long was the dog on its side for the first radiograph?

i agree that it seems to be a frustrating case!

RE: thoracic x ray interpretation

Chris Barker — Tue, 22 Sep 2015 07:15:45 GMT

We'd always love to have better x-rays...but you are working under the usual constraints of first opinion practice so as a first opinion practitioner let's work with what we've got. It's difficult to believe that we have the usual heart disease (HCM, endocardiosis) with consequent pulmonary disease when you have a 'resting' heart rate of 65 and a vertebral heart score of 10 (from the 2nd radiograph), though I suppose some form of conduction issue could be present reducing cardiac output. You would need an ecg to confirm/deny this.

I am struck by the difference between the two views, which I assume are R and L lateral. On the second view the caudal border of the heart looks normal, with no evidence of an enlarged L atrium. On the first xray the caudal border is slightly upright but the bronchi in this view seem visible due to other disease processes rather than tilting of the carina, so again I'm unconvinced by the idea that heart disease -> enlarged L atrium -> compression of a main stem bronchus plus cardiogenic pulmonary oedema.

Interpretation of lung fields is always difficult in the older dog (stated age, advanced OA of elbow) as wear and tear will cause a degree of increased bronchial patterning. But I am struck by the difference between the two views taken, on which no-one so far has chosen to comment. The lungs in the second view look relatively normal - a little streaking in the cranial lung fields (?movement blur ?pathology in the other lung) but basically good lungs. Where's the 'cardiogenic oedema' on this side? No evidence of pleural effusion this view. So is this pathology unilateral? There is a strange rippling of the ventral wall of the caudal trachea in the second view - a contrast between the air in the trachea and an unusual soft tissue density overlying/below - not sure of the pathological process which would cause this but could this be related to problems in the other lung?

Back to xray one. The cardiac shadow less discrete on this view - unless there is pleural effusion (?slight scalloping of the cranial lung field cranially but no other interlobar fissures are visible) then this will be due to pathology of the overlying lung. The branching of the bronchial tree is very clear close to the carina; the bronchial walls are quite thick (?age related change ?truly thickened by bronchitis ?highlighted by increased soft tissue density surrounding/overlying them due to pathology in the lung). Whatever the cause they are very different from the appearance of the bronchi in the second radiograph. The dorsal lung fields have a greatly increased density - not entirely uniform so I suspect there is some air still present in some alveoli. Fluffy density usually equates to fluid (oedema/pneumonic exudate/haemorrhage) But some fine, overlapping metastatic tumours can also look granular and have a similar appearance.

So you have the classic problem that xray are not always definitive! You have to link them to clinical findings, and I cannot convince myself that this is caused by the heart - lungs changes are predominantly one-sided and the cardiac signs don't fit. Unilateral lung disease? Perhaps bronchitis -> pneumonia, possibly a weird neoplasia. However there are no edge effects (normal lobe butting up against an abnormal lobe) to really support the neoplasia idea. Certainly frusemide might clear the lung fields enough to get a better view of both the lungs and the heart outline on repeat xrays, and a VD/DV view would confirm/deny whether it is unilateral. Scan to evaluate the heart, ecg for conduction issues - but we're immediately back to the financial constraints of an owner with an old dog which they haven't exactly rushed to get investigated!

But what do I know....

RE: thoracic x ray interpretation

Robin Grimmer — Mon, 21 Sep 2015 13:38:39 GMT

see my comment on above.