For an experienced practitioner and a simple view, maybe it takes a minute to thoroughly view all structures in the image. For a new veterinarian or a view that requires an extra detailed look, maybe five minutes. And if the x-ray image contains an unexpected, abnormal finding, maybe that adds on significantly more time for thinking, researching, creating rule out lists, and wondering what the finding could be. Once time is added for additional views and obtaining permission from the client for the additional views, maybe 30-60 minutes have been used up and the veterinarian is behind schedule. Busy veterinarians can benefit from saving time and preventing unnecessary worries whenever possible. To that effect, it helps to be aware of a few normal findings that are commonly mistaken for lesions in veterinary patients—specifically, wet fur, nipples, and the cecum.
For Wispy or Linear “Lesions,” Check the Patient’s Fur
A common culprit you may see on radiographs is wet fur, which shows up on x-rays images as linear or wispy marks. Sometimes, it’s obvious that wet fur is the issue. However, when analyzing organs within the abdomen or thorax with fur overlying the view, these wispy marks might obscure important details or even look like a lesion or abnormal finding such as peritonitis or an abnormal lung pattern. Plus, if the patient has very matted fur or debris/dirt in their fur, these can create additional artifacts in x-ray images.
To prevent these situations, instruct your staff to dry the fur of any patients who come in wet and to tell clients you may need to clip away matted fur. On rainy days, it may be helpful to have towels or a grooming dryer on hand for x-ray patients. Taking 2-3 views can also help provide clarity by demonstrating exactly where any suspected lesions are located—i.e. wispy marks might appear to be inside the abdomen on a VD view, but are clearly seen outside of the patient (in their fur) on a lateral.
Small Nodules in the Abdomen or Thorax Could Be the Patient’s Nipples
At least once in their career, many veterinarians are shocked and concerned to discover a small nodule(s) in the lungs or abdominal cavity of a patient who is otherwise healthy. Then, after some consideration and maybe getting a second opinion from a colleague, the vet is relieved there’s nothing wrong after all—and maybe they have a good laugh once they realize what the “lesion” actually is.
We’re talking, of course, about the patient’s nipples—which can be surprisingly easy to mistake for masses! For example, on a VD view in particular, the nipples are aligned in such a way that they appear to be inside the body rather than outside. Their appearance (small and circular) makes them look like nodules or even like stones in the bladder, kidneys, or urethra. And even after gaining experience reading a lot of images, it’s still easy to forget about nipples while trying to read a radiograph in the middle of a busy day.
To avoid spending too much time worrying about a possible mass (or discussing it with a worried client), keep nipples as a rule out in the back of your mind. Take at least two, orthogonal views, since different angles may provide clarity. And if there’s any doubt, add a drop of Barium to each nipple and repeat the x-rays—if the “nodule” turns bright white, you’ll know it’s a nipple and not a true lesion.
The Cecum May Mimic an Intestinal Obstruction
The cecum—a structure that is often gas-filled and shaped like a “C,” comma, or spiral—is located where the ileum meets the colon and is most commonly visualized in the central abdomen just right of the midline in dogs (and less commonly in cats, who have a smaller cecum). This structure sometimes makes radiographic interpretation difficult, especially for patients who have a suspected GI obstruction—since the unmoving gas can look a lot like dilated intestinal loops.
To aid future interpretations, it helps to practice looking at the cecum on normal radiographic images in healthy patients. For a patient who’s currently ill, try repeating the radiographs at appropriate time intervals, watching for movement of gas, food, or feces in all parts of the GI tract you can see and interpreting findings in light of how the patient is doing clinically. A GI contrast study may also provide clarity in patients who are good candidates for it.
One caveat: Sometimes, an abnormal-looking or very distended cecum can be a significant finding, which may require further investigation or at least repeated radiographs to see if the dilation persists.
Efficient radiographic interpretation comes with experience, but even experienced practitioners can occasionally be surprised by a normal finding that appears abnormal. These examples are three common scenarios that can cause wasted time and worry.
By remembering wet fur, nipples, and the cecum as commonly confounding radiographic findings, it may help save time and prevent unnecessary concerns.
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