CHAPTER 10
Ultrasonography
Ultrasound has been used in small animal medicine routinely
for more than 20 years. It is likely the most important imaging
modality other than radiography. Early sonographers of reptile
patients adapted this procedure to the special anatomic situa-
tions encountered within the wide range of this class.1-4 With
continuing advances in ultrasound machines and transducers,
the often small size of reptilian or amphibian patients is less of
an obstacle. It is possible to perform ultrasound even in small
geckos or chameleons, with transducer frequencies of 10, 12,
or even 18 MHz. However, several unique considerations still
must be kept in mind during ultrasound evaluation of these
species.
EQUIPMENT
Given the advances in ultrasound technology and equipment
over the last several decades, good-quality scanners with
high-frequency transducers are available for a reasonable
price. A single typically recommended ultrasound equipment
setup does not exist because of the wide range of anatomic
situations that may be encountered in reptiles. One example
of a standard machine is MyLab30Gold Vet (Haslauer-­
Medizintechnik/Esaote Europe). Depending on the body
shape and size, linear, convex, and sector probes may be used
(Figure 10-1). For snakes and lizards the linear transducers
are generally recommended (Figure 10-2). For chelonians,
a sector transducer or convex transducer with a small foot-
print is advantageous because it fits in the small sonographic
FIGURE 10-1 Ultrasound probes from left to right: phased
array probe 5 to 7.5 MHz; microconvex probe 5 to 8 MHz;
linear probe 10 to 18 MHz from Haslauer-Medizintechnik/
Esaote Europe.
Claudia Hochleithner and
Mason Holland
windows cranial and caudal to the thoracic limbs and cranial
of the pelvic limbs. The frequency of the transducer depends
on the size of the animal to be examined. High-frequency
transducers have the advantage of superior spatial resolution,
yielding excellent detail of superficial structures but have a
limited depth of penetration. Lower frequency transducers,
although lacking in fine anatomic resolution, have the ability
to penetrate deeper into tissue. In small lizards, therefore,
high-frequency transducers (10 to 18 MHz) yield the best
results. In larger lizards, such as iguanas, 7.5 to 10 MHz linear
or convex transducers are recommended. For larger patients
such as giant tortoises, frequencies from 2.5 to 5 MHz are
recommended.5-14
Special Considerations
Not only must the equipment and sonography suite be adapted
to the special situations presented by reptile patients but the
practitioner must also be aware of the wide variation in norms
among the various species that may be encountered. There is a
tendency to overinterpret normal structures in unfamiliar species,
and whenever possible, known standards should be consulted,
whether it be a different animal of the same or similar species or a
published description of normal findings in that species.
It is difficult to accumulate expertise and perform a
t­horough evaluation when sonographic evaluations are limited
FIGURE 10-2  Performing ultrasound with a linear probe on a
Boa Constrictor in a longitudinal plane; the green light indi-
cates the cranial orientation of the indicator mark.
107
108 SECTION I   •  ADVANCES IN REPTILE MEDICINE

to short periods of available time between appointments. Ultra-

sonography, especially in unfamiliar species, is not a quick
procedure. Therefore the office should be comfortable for the
sonographer and the client, as well as for the persons han-
dling the patient. A dim but not completely darkened room
provides the best environment for viewing the monitor during
the examination.
Proficiency in reptile ultrasonography is not easily acquired.
Basic technical ultrasound skills needed to use the equipment
and accurate interpretation of the findings are necessary. It is
very advantageous to have experience in small animal ultraso-
nography in order to gain familiarity with the scanning tech-
nique and operation of the machine. Small animal patients are,
in general, easier to evaluate and have a more uniform, famil-
iar anatomy.1-4 When the sonographer has accumulated this
basic knowledge, the variable reptile anatomy and the unique
sonographic appearances of reptile organs are more easily
interpreted. Published literature describing the different rep-
tilian species must be available, and special knowledge should
be acquired during seminars, conferences, and laboratories.
To improve image interpretation skills, one may also evaluate
the organs of postmortem specimens in a water bath (Figure
10-3). This reduces artifacts caused by skin, scales, and other
surrounding tissues and allows a more thorough evaluation of
the viscera. Any abnormalities detected can be correlated with FIGURE 10-3 Water bath for investigating postmortem
histopathologic findings (Figure 10-4,) to clarify the etiology organs or tumors after surgery; results can be compared with
of the disease process. histopathologic findings or can be used for self-training.

Testicle

Kidney
Kidney

b b

A B
FIGURE 10-4  A, Post-mortem kidney and testicle ultrasound image in water bath; Greek
Tortoise (Testudo hermanni). B, Histopathologic diagnosis of changes in kidney of the
Greek Tortoise from A. Section of the kidney with calcium microlite (a) and dusty deposi-
tion of calcium within the glomerulus (b). Magnification, ×400. (Dr. Anna Kuebber-Heiss,
Research Institute of Wildlife Ecology, University of Veterinary Medicine Vienna.)

PATIENT PREPARATION
Positioning of the patient must be adapted to what the patient
will tolerate while allowing access to the anatomic regions of
interest. Typically, dorsal recumbency is the most useful posi-
tion, but an upright position may also be helpful, especially in
weak lizards and in iguanas (Figure 10-5). Large snakes need
more personnel to hold them comfortably for this procedure.
In aggressive reptiles, sedation should be used to minimize the
stress for the animal and the risk to the patient or the technicians.
It is important to develop a routine scanning technique
that covers all typically visible organs so that an important
sonographic finding is not missed. Whenever possible, each
organ should be scanned in two planes: usually transverse
and sagittal/longitudinal. Oblique scanning planes are also
frequently used to evaluate organs and pathology of variable
shape and anatomic location. The probe should always be held
in the same fashion such that the sonographer is oriented to
the spatial relationship between the tissues being scanned and
their appearance on the screen.5-9,13,14 Standard convention
FIGURE 10-5 Upright positioning for weak patients. A
Bearded Dragon (Pogona vitticeps) is held while ultrasound
is performed.
CHAPTER 10   • Ultrasonography 109
dictates that when the patient is in dorsal recumbency, the
head is on the left side or facing away from a right-handed
sonographer and the transducer is gripped so that the indica-
tor of the probe shows either cranially or to the right side of
the patient’s body (Figures 10-6 through 10-9). When this
technique is used, the left side of the image on the monitor
is cranial in a longitudinal/sagittal view and represents the
patient’s right in a transverse view (Figure 10-10).
The body shape of the snake lends itself to examination
from cranial to caudal in longitudinal and transverse scanning
planes. In chelonians, there are only three accessible sono-
graphic windows: cranial to the forelimb beside the neck (to
investigate the heart and the liver), in the axillary region (for
the heart and the liver), and in the inguinal, prefemoral win-
dow (to assess the intestine, urogenital tract, and the bladder)
(Figure 10-11). In soft-shelled chelonians, it is possible to scan
the coelomic viscera through the plastron. This is occasionally
FIGURE 10-6  Positioning of the probe in a longitudinal view
of a Bearded Dragon (Pogona vitticeps).
FIGURE 10-7  Sagittal plane image of an egg in the Bearded
Dragon (Pogona vitticeps) from Figure 10-6. The hyperecho-
genic oval structure is the shell, the hypoechoic part is the
albumin, and the rest of the content is the developing vitel-
logenic mass, shortly before being oviposited.
110 SECTION I   •  ADVANCES IN REPTILE MEDICINE

FIGURE 10-8  Positioning of the probe in a transverse imag-

ing plane in a Bearded Dragon (Pogona vitticeps).

FIGURE 10-10  In dorsal recumbency, the head of the reptile

is on the left side or facing away from a right-handed sonog-
rapher, so the indicator of the probe shows either cranially (in
this picture) or to the right side of the patient’s body.

FIGURE 10-9 Transverse plane image of an egg in the

Bearded Dragon (Pogona vitticeps) from Figure 10-8.

also possible in diseased chelonians if they have a poorly min-

eralized plastron (Figure 10-12).
Ample coupling gel must be applied to the skin surface.
A gel bottle warmer should be used to prevent cooling of the
patient. Better images can be obtained if the skin is moistened
with warm water before the coupling gel is applied because
contact is improved and trapped air bubbles that attenuate the
sound beam are reduced. In chelonians and small patients, a
stand-off pad to fill the space between the skin and the trans-
ducer surface may be helpful. An examination glove filled
with warm water is a useful and substitutes for an inexpensive
stand-off pad that can easily conform to the desired shape
(­Figure 10-13). Coating the standoff pad with coupling gel
further enhances the image quality.
If the pressure of the probe on the patient’s body is exces-
sive, artifacts and inaccurate findings may result; excessive
transducer pressure can result in compression and displace-
ment of organs from their normal position, especially in
snakes.
FIGURE 10-11 Prefemoral window to assess the intestine,
urogenital tract, and the bladder in tortoises.
Although ultrasound is an excellent tool to investigate
the organs of the coelomic cavity, some circumstances can
complicate this procedure. Patients undergoing or soon to be
undergoing ecdysis are poor candidates because air between
the layers of the skin attenuates the majority of the sound
beam, resulting in poor penetration of deeper tissues. Some
species with ossified scales (e.g. Tiliqua spp. and Heloderma
spp.) are also poor candidates because the ossified scales hinder
penetration of the ultrasound beam.
 CHAPTER 10   • Ultrasonography 111

Free liquid
in coelomic
cavity

Kidney

A B
FIGURE 10-12  A, In diseased tortoises, it may be possible to scan the coelomic viscera through
the plastron. B, Ultrasound image of the coelomic cavity of a diseased tortoise with renal
failure due to secondary nutritional hyperparathyroidism combined with mismanagement of
husbandry.

FIGURE 10-13  In tortoises, an examination glove filled with
warm water can be used as a stand-off pad in the prefemoral
window.
SCANNING PATTERN
The geometrically simple shape of the snake lends itself to
the most straightforward method of sonographic examination.
The heart is a useful starting point for establishing appropriate
depth and settings on the machine. Blood in the vessels and
chambers should be slightly hypoechoic to the cardiac muscle,
and the valves should appear as hyperechoic lines. The body
must to be scanned in saggital, transverse and dorsal (coronal)
views caudally to the level of the cloaca (Figure 10-14).
In lizards, the liver and the gallbladder should be evaluated
first. Adjustments should be made to the machine to at this
time to tune image quality before proceeding to the rest of the
exam. Next, the examination should move cranially to investi-
gate the heart and then back again caudally with transverse and
longitudinal views to investigate the fat bodies, gastrointestinal
tract, gonads, bladder, and, finally, the kidneys.
Chelonians, except for soft-shelled species, are a little more
challenging because they only have three useful acoustic windows
to the coelomic cavity.12
The individual coelomic viscera are investigated by measur-
ing the size, shape, and margination of each organ. Changes
in echogenicity, either focal or diffuse, can be visualized and
interpreted. The gastrointestinal tract is investigated as in
small animals for motility, mural thickness, patency, and for-
eign content. With high-frequency transducers, intestinal wall
layering can be appreciated (Figure 10-15).
The gonads are to be evaluated for size and shape in order
to interpret the reproductive stage in both sexes. The kidneys
are monitored for size and changes in echogenicity. The uri-
nary bladder, when present, should be investigated for foreign
material (e.g., calculi or ectopic eggs). Free coelomic fluid can
be detected and assessed for echogenicity, amount, and cellular
or solid content.
112 SECTION I   •  ADVANCES IN REPTILE MEDICINE
FIGURE 10-14 The simple shape of the snake lends itself
to the most straightforward method of sonographic exami-
nation from cranial to caudal. All three planes should be
scanned: sagittal, transverse, and dorsal.
Stomach
wall
FIGURE 10-15  Ultrasound image of the different layers of the
wall of the stomach of a Savannah Monitor (Varanus exanthe-
maticus). The first layer is the small hyperechoic line of the
serosa, followed by the low echogenic muscularis layer; next
is the higher echogenic submucosa, then the less echogenic
mucosa, and the last layer is the highly echogenic mucosal
surface, beneath which is seen the content of the stomach
as an heterogeneous mass with some parts showing distal
attenuation of the ultrasound beam (gas).
INDICATIONS
Ultrasound is often used as a tool for further imaging of a sus-
pected abnormality, although, in many circumstances, ultraso-
nography has a clear advantage over radiology or endoscopy
and may be chosen as the primary imaging modality.
Coelomic enlargements of unclear origin (e.g., tumors and
ascites), along with reproductive monitoring, are the most com-
mon indications for ultrasonography. Any kind of enlargement
on the animal’s body can be scanned and interpreted to better
characterize the nature of the swellin­g. ­Ultrasound-guided aspi-
rates and biopsies may also be performed, but the need for these
procedures should be evaluated in conjunction with possible
risks such as organ perforation and hemorrhaging.15,16 Reptile
echocardiography is a relatively young field, but with improving
equipment and continuing publications, the practical clinical
utility of this will continue to increase.
THE HEART
Reptilian hearts, except those of the crocodilians, have three
chambers: two atria and one (normally) thick-walled ventricle,
which should not be mistaken for hypertrophic cardiomyopa-
thy. The ventricle is divided by muscular septae in three sub-
chambers: the cavum venosum, cavum pulmonale, and cavum
arteriosum. The blood flows from the sinus venosum where
the venae cavae join before emptying into the right atrium.
From the right atrium, the deoxygenated blood flows to the
cavum venosum and further on to the cavum pulmonale,
which is the most ventral portion of the chamber. From there,
blood passes via the pulmonary arteries to the lung. Oxygen-
ated blood flows from the venae pulmonales to the left atrium
and from there to the cavum arteriosum. During systole, the
blood is circulated through the still partially contracted cavum
venosum in the main circulation arteries.17-20 All reptiles also
have paired aortic arches, which are united to the aorta dorsa-
lis. The atrioventricular valves are aligned such that they par-
tially occlude the interventricular canal during atrial systole.
During ventricular systole, they should prevent regurgitation
of blood from the ventricle to the atria.
The most useful plane for investigating the reptilian heart is
the sagittal plane (Figure 10-16, A, B). The second plane is the
short-axis view, which is obtained by holding the transducer
in a tranverse position, scanning the heart and the vessels from
caudal to cranial (Figure 10-16, C, D). If the heart is cranially
positioned, as it is in many lizards, it may be easier to view the
heart from the left or right axillary region. For tortoises, the
cervicobrachial window is applicable (Figure 10-17).
Changes in the size and the shape of the heart, contractil-
ity, and the pericardium can be assessed. A small amount of
anechoic fluid in the pericardial space is normal (Figure 10-18).
Congenital and infectious diseases resulting in cardiac changes,
such as endocarditis and myocarditis, have been described in
the literature. Valvular disease, myocardial abnormalities, atrial
thrombi, and neoplasia can be detected. The development of heart
failure can be monitored with Doppler and M-mode measure-
ments.21-25 Uric acid crystal deposition within the myocardium or
in the pericardial sac due to gout can be visualized (Figure 10-19).
 CHAPTER 10   • Ultrasonography 113

LAo
RAo
Ventral

LA
RA

CP
PA LAo

CV MR
PA
Cranial Caudal

RA
V

A B Dorsal
V

Ventral SAV
2

Left RA
LAo SV
RAo 4
Right LA

RA PA

C Dorsal

FIGURE 10-16  A, Ventral aspect of the heart in a Burmese python (Python molurus
bivittatus) after resection of the pericardial sac. B, Echocardiographic examination in a
Red-tailed Boa (Boa constrictor imperator). Long-axis view, right atrioventricular sec-
tion. C, Echocardiographic examination in a Ball Python (Python regius). Short-axis
view, transarterial section “Mickey Mouse Head” section  (Photographs A-C courtesy L.
Schilliger.)  D, Echocardiographic examination in a Burmese Python (Python molurus
bivittatus). Short-axis view, transatrial section (thickness because of suspected endocar-
ditis).  (Photograph courtesy V. Cherboul.)  CP, Cavum pulmonale; CV, cavum venosum;
LA, left atrium; LAo, left aortic arch (left aorta); MR, muscular ridge; P, pericardium; PA,
pulmonary artery; RA, right atrium; RAo, right aortic arch (right aorta); SAV, sinoatrial
valves; SV, sinus venosus; V, ventricle.
114 SECTION I   •  ADVANCES IN REPTILE MEDICINE

FIGURE 10-17  For investigation of the heart in tortoises, the
transducer is placed into the cervicobrachial window on both
sides.
THE LIVER
The liver is characterized by a homogenous hypoechoic tex-
ture with anechoic vessels. In lizards and chelonians, the liver
is bilobed. The anechoic gallbladder is attached to the right
lobe8,26 (Figure 10-20). With proper equipment, the portal
vein, hepatic veins, and the caudal vena cava can be individu-
ally assessed (Figure 10-21).
In snakes, the liver extends caudally from the level of the
lungs, where it occupies approximately the middle third of
the length of the body. Two large vessels (the Vena hepatica
portalis located dorsally, and the Vena hepatica ventrally)
run from cranial to caudal through the length of the organ
(Figure 10-22). The anechoic gallbladder is not associated
with the hepatic parenchyma as it is in lizards and chelonians.
Rather, the gall bladder is caudal to the liver and is visible as
an anechoic round or slightly oval structure8,9 (Figure 10-23).
The liver can usually be easily differentiated from the fatbody
(Figure 10-24).

Liver
Free fluid Pericardium
in pericardial Liver GB
space

Ventricle
apex Gas in
oesophagus

FIGURE 10-18 Free fluid in the pericardial space can be

monitored during routine investigation. In this Green Iguana
(Iguana iguana), the amount is slightly increased because of
early cardiac and renal failure.
Heart
FIGURE 10-20 Ultrasound image of the homogenous
hypoechogenic texture of the liver with the anechoic gall-
bladder attached to the right lobe in a Green Iguana (Iguana
iguana).GB, Gall bladder.

Liver
Gas marked
tissue from UA-crystals
oesophagus in myocardium

FIGURE 10-19 Mineralization, presumably uric acid crystal

deposition in a Black-headed Monitor (Varanus tristis) due to
renal disease can be seen in the myocardium as hyperechoic
foci.
 CHAPTER 10   • Ultrasonography 115

CVC Gallbladder
HV

FIGURE 10-23 The gallbladder of snakes, here a Western

Hognose (Heterodon nasicus), appears as a round to oval
anechoic structure caudally separated from the liver.
PV

B GB
Liver Fatbody
FIGURE 10-21  A, Oblique plane ultrasound image showing a
hepatic vein (HV) entering the caudal vena cava (CVC) within
the liver of a healthy Green Iguana (Iguana iguana). B, Sagittal
plane ultrasound image showing the portal vein (PV) in a
healthy Green Iguana originating in the caudal coelom and
arborizing into the liver (L) on the left side of the image. ((Photo Gas filled
courtesy Dr. Mason Holland, Portsmouth, NH.) stomach

FIGURE 10-24 Ultrasound image of the echotexture of the

liver in comparison with the higher echogenicity of the fat-
body and the characteristic hyperechoic lines in between the
fat in a Green Iguana (Iguana iguana). Between the liver and
the fatbody is the gas-filled stomach, causing distal attenua-
Liver
tion of the ultrasound beam. GB, Gall bladder.
Hepatic vein

FIGURE 10-22 Sagittal plane image of the homogenous

hypoechoic liver with the central hepatic vein in a Ball Python
(Python regius). In this image, only the ventral Vena is seen
as the probe is held slightly paramedian.
116 SECTION I   •  ADVANCES IN REPTILE MEDICINE

Size and echotexture of the liver should be assessed;

changes can be either focal, multifocal (Figure 10-25), or
diffuse throughout the organ. These changes can be distinctly
or indistinctly marginated, which can give a hint to the under-
lying process. Hyperechogenicity and enlargement of the liver
are seen in connection with fatty liver degeneration (Figure
10-26). An heterogeneous pattern of the liver parenchyma
with anechoic areas is common with focal necrosis or inflam-
mation. Anechoic round or oval structures can be visualized
in connection with cystic change (Figure 10-27). Hyperechoic
particles in the gallbladder can be visualized as signs of thick-
ening of the bile. Hyperechoic and heteroechoic lesions, usually
focal and occasionally attached to the gallbladder, may represent
abscessation14 (Figure 10-28).

FIGURE 10-27  Ultrasound image of multiple anechoic struc-

tures in the liver of a Kingsnake (Lampropeltis sp.)—cysts,
sagittal plane. On histopathologic examination, the changes in
the liver were determined to represent cystic adenocarcinoma.

Hyperechoic
material
in the
gallbladder
and liver

FIGURE 10-25 Ultrasound image of the liver (margins indi-

cated with arrows) of a Western Hognose (Heterodon nasicus)
showing a highly heterogenous pattern through the whole
liver with round to oval anechoic structures—cystic changes.
On histopathologic examination, it was diagnosed as liver
carcinoma with cystic abnormalities.
FIGURE 10-28  Ultrasound image of hyperechoic material in
the lumen of the gallbladder and the surrounding liver tis-
sue secondary to an abscess in a Bearded Dragon (Pogona
vitticeps).

Liver Fatbody

GB

Stomach

FIGURE 10-26 Sagittal plane image of fatty liver degenera-

tion in a Bearded Dragon (Pogona vitticeps). The liver shows
greater echogenicity than the fatbody. In the middle of the
figure, deep to the gallbladder, the stomach filled with ingesta
and gas is visible. GB, Gall bladder.
 CHAPTER 10   • Ultrasonography 117

Hyperechoic lines

Liver
Fatbody Intestine wall
Ingesta
Fatbody

A
Hyperechoic lines
FIGURE 10-29  Ultrasound image of the fatbody in a Bearded
Dragon (Pogona vitticeps) with normal hyperechoic lines in
between the fat.
St

THE FATBODY
The fatbody varies in size and shape depending on the spe-
cies and body condition of the patient. Normally, they are
paired structures that lie laterally within the coelom, extend-
ing cranially from the region of the heart and liver to the
caudal abdominal region. They show a greater echogenicity B
than the liver and curvilinear hyperechoic septae between fat
lobules (Figure 10-29). Internal vasculature of the fat bodies FIGURE 10-30  A, Sagittal plane image of a portion of the
intestine in a Bearded Dragon (Pogona vitticeps) filled with
will be less than that seen within the liver, which is useful
ingesta. Intestinal layering is visible. The first small hyper-
to differentiate these two structures. The size of the fatbod- echoic layer next to the liver is the small line of the serosa,
ies can give a good general assessment of the body condition followed by the low echogenic muscularis layer; next is the
of the animal (from emaciation through obesity). If a small higher echogenic submucosa, the low echogenic mucosa,
amount of free fluid is present in the coelomic cavity (a com- and the highly echogenic mucosal surface, beneath which
mon, normal finding), the fatbodies are easily distinguished. is seen the content of the intestine (ingesta) as an het-
Abscesses or granulomas can be visualized as round, some- erogeneous mass. Below the ingesta is the intestine wall:
times hyperechoic, sharply delineated structures with central small highly echogenic line of the mucosal surface, the low
hypoechoic/anechoic regions. Dystrophic mineralization or echogenic pattern of the mucosa, and the higher echogenic
crystal formation in the fat pads are discernable by evidence submucosa, followed by the low echogenic muscularis layer;
next to the fatbody, as the last outside layer, is the small
of hyperechoic foci.
hyperechoic line of the serosa. B, Sagittal ultrasound image
of the pyloric portion of a nondistended stomach (St) in a
GASTROINTESTINAL TRACT normal Green Iguana (Iguana iguana) showing prominent
wall layering. A thick hypoechoic muscularis layer is present.
The gastrointestinal tract and the relationship between the Orad is to the right of the image.
size of the different portions varies greatly depending on
whether the reptile is a herbivore, omnivore, or carnivore. In
carnivorous reptiles, the stomach is large, and longitudinal
folds can be visualized; the intestine is smaller and shorter
compared with herbivorous animals. In herbivores, the stom-
ach is smaller, has a thin wall, and the intestine is elongated
with mucosal folds. Depending on the size of the animal and
the frequency of the transducer, intestinal wall layering can
be visualized, similar to mammals and birds (Figure 10-30).
Changes in motility, foreign bodies, and large amounts of gas
or impacted ingesta (such as sand impaction) can be visual-
ized. Intestinal gas typically results in complete reflection of
the ultrasound beam, preventing assessment of deeper tissues
and evaluation of deeper structures. This is especially true in
herbivorous species.
118 SECTION I   •  ADVANCES IN REPTILE MEDICINE
Because ultrasound is often used as a further diagnostic tool
after radiology, it should be performed before intestinal con-
trast studies. Barium has the same effect as gas or stones in the
gastrointestinal tract, absorbing and reflecting the sound beam
and limiting evaluation (Figure 10-31). Iodinated contrast
media is, however, typically sonolucent.
Gas filled intestine
FIGURE 10-31  Ultrasound image of gas in the intestine with
(distal) attenuation of the ultrasound beam in a Bearded
Dragon (Pogona vitticeps).
THE SPLEEN
The spleen is difficult to visualize because the organ is often
located deep to the intestine, and evaluation is frequently
limited by the presence of intestinal gas. Depending on the
species, it is round to oval and of variable, generally small
size; the texture is homogenous with medium echogenicity
and fine granular echotexture similar to the testes5-10,13,14,26
(Figure 10-32). In male Green Iguanas scanned during breed-
ing season (early winter in the northern hemisphere), the
spleen may be more easily seen because much of the adjacent
intestine is displaced by hypertrophy of the adjacent testes19
(Figure 10-33).
Liver
Spleen Left
testicle
FIGURE 10-32 Ultrasound image of the spleen (+) in a
Bearded Dragon (Pogona vitticeps) with adjacent intestine,
liver, and left testis.
FIGURE 10-33  Sagittal image of the spleen (S) in a healthy
male Green Iguana (Iguana iguana). Physiologically enlarged
testes have displaced overlying intestine but are not visible
in this image because they were displaced from the plane by
transducer pressure.
 CHAPTER 10   • Ultrasonography 119
THE GONADS
Ultrasonography is the imaging modality of choice for evalu-
ation of reproductive function, stage, and disease. Other
applications include gender determination, evaluation of Gas and
reproductive potential, and directing and assessing the efficacy ingesta
of therapeutic interventions.26-31 filled
Juvenile gonads are poorly visualized because they are intestine
Ovary
obscured by intestine and are frequently small in size (Figure
10-34). The gonads lie in the last third of the body lateral Ovary
to both sides of the abdominal aorta, and the right gonad is Spinal cord
slightly cranial to the left. Depending on the age of the patient
and stage of the reproductive cycle, the testes are ovoid and
vary in size from barely visible to clearly obvious; they are
especially pronounced in Bearded Dragon and Green Iguanas
during breeding season (Figure 10-35). They show a fine,
granular, homogeneous echo texture, are isoechoic to slightly
hyperechoic to liver. FIGURE 10-34 Ultrasound image in a transverse plane of
the ovary as round anechoic structures ventral and lateral to
the spinal cord in a 9-month-old Lawson’s Dragon (Pogona
henrylawsoni).

Longitudinal
view left
testicle

A B

Right
Left
testicle testicle

Right
testicle

C D
FIGURE 10-35  A, Transverse plane image of the testes in a 9-month-old Lawson’s Dragon
(Pogona henrylawsoni). The right testis lies slightly cranial to the left, showing finely
granular and homogenous echotexture. B, Longitudinal ultrasound image of the left testis
in the Lawson’s Dragon (P. henrylawsoni) from A. C, Transverse plane ultrasound image
of the testes in an adult reproductively active Bearded Dragon (Pogona vitticeps). D,
Longitudinal view of the right testicle in the Bearded Dragon (P. vitticeps) of C.
120 SECTION I   •  ADVANCES IN REPTILE MEDICINE

The ovaries may be visualized, depending on their size.

At the beginning of the reproductive cycle, the follicles are
round and anechoic. In tortoises, they show higher echo-
genicity at this early stage. The size varies from one to a few
millimeters (Figure 10-36). Before ovulation they grow to
large round structures, and their echogenicity increases. In
snakes, many anechoic, round structures can be visualized
before ovulation, depending on the size of the snake (up
to 2 cm in diameter in large pythons). In the late preovula-
tory state, nearly the entire coelomic cavity may be filled
with rounded follicles (Figure 10-37). After ovulation, the
ova elongate, and a slightly hyperechoic wall is produced.
Depending on the species, the wall of the ova will range from
noncalcified to calcified (Figure 10-38). The inside of the egg
can be monitored, depending on the degree of calcification.
At the beginning of pregnancy, the content can be distin-
guished as an anechoic layer of albumin and the hyperechoic FIGURE 10-37  Ultrasound image of the ovary before ovula-
yolk (Figure 10-39). Occasionally, a small embryo can be tion in a Bearded Dragon (Pogona vitticeps). Round struc-
visualized. In ovoviviparous snakes, the development of the tures are starting to change from anechoic to more echogenic
embryos can be monitored by the stage of development, activ- content. In this case, the Bearded Dragon developed pre-
ity, and heart beat (Figure 10-40). ovulatory follicle stasis due to management problems in the
environment.

Kidney

Ovary

Wall of
egg

A
Follicles

Wall of
egg

B
FIGURE 10-36  A, Longitudinal slightly paramedian ultrasound
image of the ovary in a Green Tree Python (Morelia viridis).
This is the beginning of the reproductive cycle, and differ-
ent sizes of round, anechoic structures are aligned cranially B
to caudally. Laterally to the ovary, the right kidney is visual-
ized. B, Ultrasound image of the follicles in a Red-eared Slider FIGURE 10-38  A, Ultrasound image (sagittal plane) of a
(Trachemys scripta elegans). In tortoises, unlike snakes and more mature egg with higher wall echogenicity in a Bearded
lizards, the follicles already show a higher echogenicity at this Dragon (Pogona vitticeps). B, Ultrasound image of the same
early stage. egg in A, in a transverse plane.

Anechoic
portion
Yolk portion
A
Anechoic
portion
B Yolk portion
FIGURE 10-39  A, Ultrasound image of eggs in a Bearded
Dragon (Pogona vitticeps) in a transverse plane with differen-
tiation of the yolk portion (more echogenic) from the albumin,
visualized as the anechoic part of the egg. B, Ultrasound
image of one of the eggs from A in a Bearded Dragon in a
sagittal plane with differentiation of yolk portion and anechoic
part of the egg.
Pathologic changes can be monitored in all stages of the
reproductive cycle. It is important to distinguish preovulatory
from postovulatory status for detection of follicle stasis and egg
binding. Normally, preovulatory follicles are uniform, round, and
either anechoic or hypoechoic. As the follicles remain unovulated,
more echogenic layers appear. In addition, the echogenicity
changes to an heterogeneous pattern, the surface of the follicles
is no longer smooth and well-demarcated, and anechoic fluid
around the follicles can be visualized with echogenic free-floating
particles in this fluid, indicating inflammation (Figure 10-41).
After ovulation, the ova change to a more elliptical, echo-
genic structure. The wall of the egg is normally smooth, and
CHAPTER 10   • Ultrasonography 121
Surface
Embryo
of egg
Yolk
A
Boa
fetuses
B
FIGURE 10-40  A, Ultrasound image of an egg filled with
highly echogenic yolk and a small embryo developing in a
Ball Python (Python regius). B, Ultrasound image just before
birth in an ovoviviparous Boa Constrictor; it is also possible
to see the movements of the fetuses and the beating hearts
at this stage.
irregularity of the surface can suggest chronicity and prognosis
in egg binding. An heterogeneous pattern of the content of
the egg combined with free fluid in either the uterus or the
coelomic cavity generally indicates a reduced reproductive
prognosis. Pyometra after multiple problems with egg binding
has been evaluated (Figure 10-42).
Ultrasound may also be useful in monitoring pathologic
changes in the gonads. Gonadal origin of coelomic tumors is
often difficult to confirm because of the variable appearance
of the gonads, and this may be a diagnosis of exclusion, after
successful identification of other normal-appearing coelomic
structures (Figure 10-43).
Old
follicles

A B
FIGURE 10-41  A, Ultrasound image of older preovulatory follicles before surgery in a
Bearded Dragon (Pogona vitticeps). The echogenicity increases and becomes slightly
heterogeneous with aging of the follicles. B, Preovulatory follicle stasis in the Bearded
Dragon from A. The content of the follicles firms with progression of stasis.

Uterus
filled with
fluid

A B
FIGURE 10-42  A, Ultrasound image of the abdomen of a Veiled Chameleon (Chamaeleo
calyptratus). The curved tubular structure with anechoic content visualized on the left side
of the caudal coelom represents an accumulation of purulent material in the salpinx. B,
Salpinx from the Veiled Chameleon in A filled with purulent exudate after surgery.

Liver

Free fluid in Tumor

abdomen

A B
FIGURE 10-43  A, Ultrasound image of an heterogeneous mass with anechoic patches distrib-
uted multifocally throughout the mass. A large amount of anechoic free fluid was found in the
coelomic cavity of this Green Iguana (Iguana iguana). B, After aspiration of 750 mL free fluid and
surgical removal of the tumor, the tissue was histologically investigated. The diagnosis was a
cystic adenocarcinoma of the ovary of the Green Iguana from A.

URINARY BLADDER
The urinary bladder, when present, lies in the caudal portion
of the coelomic cavity and has a thin, smooth, hyperechoic
wall. The content is anechoic with hyperechoic particles or
larger aggregates (uric acid particles) (Figure 10-44).32 Urate
aggregates show a typical snowflake-like pattern, especially
when the patient is moved. Calculi can be distinguished by
their more solid structure and the distal shadowing of the
UB
T
FIGURE 10-44  Sagittal plane ultrasound image in a healthy
Green Iguana (Iguana iguana) showing an aggregate of echo-
genic urates suspended within the urinary bladder (UB). A
testis can also be seen (T). The urinary bladder is thin walled
and conforms to the surrounding organs.
CHAPTER 10   • Ultrasonography 123
ultrasound beam. Pathologic changes can be seen in tortoises
with egg retention or dystocia. Eggs may occasionally retro-
pulse back into the bladder as they pass through the urodeum.
They appear as large, round, multilayered structures within
the urinary bladder. In these cases, the outer surface of the
egg shows an irregular wall, with internal echogenic material.
The urinary bladder wall may also be thickened because of
mechanical irritation (Figure 10-45).
Wall of anal
bladder
Inflammatory
material
Stone
A
B
FIGURE 10-45  A, Ultrasound image of the anal bladder in a
30-year-old Greek Tortoise (Testudo hermanni). The hyper-
echoic tissue of the anal bladder is thickened, and a calculus is
visible as a line with distal extinction of the ultrasound beam.
Between the two structures is a thick layer of inflammatory
reaction and fibrin. B, The calculus with gel-like material on the
surface. The cause of the calculus was determined to be the
long-term presence of an egg in the lumen of the anal bladder.
124 SECTION I   •  ADVANCES IN REPTILE MEDICINE
THE KIDNEYS
The kidneys show a higher echogenicity than the liver and
the fatbody, with a clear granular echotexture and a distinctly
marginated surface. In snakes, they are elongated and lobes
can be visualized; however, no hyperechoic septae can be
visualized, unlike in the fatbody, which allows differentiation
of these structures. In some lizards, like the common Green
Iguana or the Bearded Dragon, the kidneys lie within the pelvis
and are not easily seen (Figure 10-46). In other groups, such
as the varanids, the kidneys are midcoelomic and are readily
scanned.
UB
K C
K
FIGURE 10-46  Transverse plane ultrasound image in a healthy
Green Iguana (Iguana iguana). The cranial poles of the kidneys
(K), which lie within the pelvic cavity in this and similar species,
can occasionally be seen by angling the transducer caudally at
the pelvic inlet, as in this image. C, Colon; UB, urinary bladder.
Pelvic girdle
Enlarged
kidney
FIGURE 10-47 Ultrasound image of an enlarged kidney (+)
in a Bearded Dragon (Pogona vitticeps) protruding cranially
from the pelvic cavity.
In patients with intrapelvic kidneys, when renomegaly is
present, the cranial poles of the kidneys can be visualized just
cranial to brim of the pelvis26,33 (Figure 10-47). In the iguana,
an acoustic window just caudal to the pelvis may provide the
best visualization of the kidneys.
Often large hyperechoic granules due to renal failure/gout
can be detected and monitored in enlarged kidneys (Figure
10-48). Anechoic spherical structures, occasionally multifocal
throughout the organ, indicate cystic changes (Figure 10-49).
Mineralization, with the characteristic appearance of distal
attenuation of the ultrasound beam, can be seen; tumors may
also be detected (Figure 10-50).
Testicle Kidney
Free fluid
FIGURE 10-48  Ultrasound image of an enlarged kidney in a
Greek Tortoise (Testudo hermanni) with large hyperechoic
granules in the tissue, as a result of renal failure. A large
amount of free fluid was found in the coelomic cavity (same
tortoise as Figure 10-12).
Gas Intestine
Kidney
Cyst
FIGURE 10-49  Ultrasound image of the kidney of a Kingsnake
(Lampropeltis sp.) with anechoic spherical structures in the
tissue. A cystic abnormality of the renal tubules is seen on
the surface of the kidney (same animal as Figure 10-27). The
intestine is filled cranially (on the left of the picture) with gas
and caudally with fluid ingesta.

Calcification
in kidney
FIGURE 10-50 Ultrasound image of the kidney of the
Kingsnake (Lampropeltis sp.) from Figure 10-27 and 10-49.
The whole organ shows a slightly heterogeneous pattern.
Focally there is a highly echogenic structure with distal atten-
uation of the ultrasound beam. On histopathologic examina-
tion, the changes in the kidneys were consistent with cystic
adenocarcinoma with focal calcifications.
THE EYE
Because of the small size of the normal reptilian eye, high-
frequency transducers with a small footprint should be used to
obtain a good image of the structures of the eye and the sur-
rounding tissues. The coupling gel and the probe can be placed
either directly on the cornea, the spectacle, or the eyelids (as in
chameleons). Both eyes should always be investigated in sagit-
tal, dorsal, and transverse planes for a thorough evaluation and
bilateral comparison.
The image of the normal cornea and the attached spectacle
in snakes is a small, parallel, hyperechoic two-lined struc-
ture. Posterior to the cornea, the anechoic anterior chamber
is visible. The lens is an oval, anechoic structure with thin
hyperechoic margins. The iris is slightly heterogenous of
CHAPTER 10   • Ultrasonography 125
Eyelid
Lens
Vitreal
body
FIGURE 10-51  Ultrasound image with an 18 MHz transducer
of a healthy eye in a Veiled Chameleon (Chamaeleo calyptra-
tus). The most superficial echogenic structure is the eyelid;
the lens appears as an oval, anechoic structure with thin
hyperechoic margins; the vitreal body is anechoic; and there
is a round border to the fundus.
medium echogenicity, and, especially in small reptiles, not easily
distinguished from the ciliary body. The vitreal body should
be anechoic, and the fundus of the globe should be uniformly
concave. The conus papillaris is visualized as a higher echo-
genic structure reaching from the posterior pole of the wall
into the vitreal body. Its size ranges from a small structure to
a large structure reaching almost to the posterior lens capsule
wall (Figure 10-51).
Changes associated with dysecdysis in snakes, intraocular
hemorrhage, abscesses, and tumors of the structures of the eye
and the orbit can be visualized (Figure 10-52).
Probes with frequencies from 40 to 60 MHz will give even
more detailed images. In ophthalmology, this technique is
referred to as ultrasound biomicroscopy.33
126 SECTION I   •  ADVANCES IN REPTILE MEDICINE

Bulbus

Eye

Retrobulbar
mass

Orbit

Retrobulbar mass

A D

Retrobulbar mass
Retrobulbar
mass

E
B

C
FIGURE 10-52  A, Ultrasound image with an 10 MHz transducer of an abnormal posterior
wall of the globe in a different Veiled Chameleon (Chamaeleo calyptratus). There is a large
heterogenous hyperechoic mass visible posterior to the globe. B, Ultrasound image of the
heterogeneous hyperechoic retrobulbar mass from the Veiled Chameleon in A. On histo-
pathologic examination, it was diagnosed as soft tissue sarcoma. C, Retrobulbar tumor
in the Veiled Chameleon from A and B. D, Postmortem view from the head of the same
Veiled Chameleon from A-C after opening the eyelid cranially and lifting up the bulbus.
The retrobulbar mass had already spread underneath the eyelid. E, Postmortem view from
the head of the same Veiled Chameleon from A through D after removal of the bulbus to
get a view of the orbit, which is completely filled with the retrobulbar mass.

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