Pancreas Felino

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ULTRASONOGRAPHY O F TH E NORMAL FELINE PANCREAS ANDASSOCIATED ANATOMIC LANDMARKS: A PROSPECTIVE STUDY OF

20 CATSSHEILA. ETUE,DVM, DOMINIQUE. PENNINCK,VM, DVSc, M A R Y NNA ABATO,VM,SUSANEARSON,A, CVT, A M YTIDWELL,VM

The sonographic appearance of the feline pancreas and associated anatomic landmarks including thepancreatic duct, duodenum, duodenal papilla, portal vein, and gastric lymph node were evaluated in 20healthy, awake cats. The pancreas appeared nearly isoechoic to surrounding mesenteric tissues, iso-echoic to slightly hyperechoic to adjacent liver lobes, and hypoechoic to the spleen. The mean thicknessmeasurements for the right pancreatic lobe, body, and left pancreatic lobe were 4.5 mm (range 2.8-5.9),6.6 mm (range 4.7-94, and 5.4 mm (range 3.4-9.0), respectively. The pancreatic duct was consistentlyvisualized in the left pancreatic lobe and had a mean thickness of 0.8 mm (range 0.5-1.3). It could bedifferentiated from the pancreatic vessel, by its central location, and the ducts lack of Doppler flowsignal. The duodenum was used as a landmark to identify the right lobe of the pancreas. The meanduodenal wall thickness measurement was 2.8mm (range2.1-3.8) in sagittal section, and 3.0mm (range2.2-4.4) in transverse section. The duodenal papilla was identified in 4 of 20 cats. It ranged in size from2.9 to 5.5 mm in width, and had a maximum height of 4.0mm in transverse section. The portal vein wasused as a consistent anatomic landmark for identification of the left lobe and body of the pancreas. Themean diameter of the portal vein at the level where the pancreatic body joins the left pancreatic lobewas 4.3 mm (range 2.7-5.9) when viewed in sagittal section, and 4.5 mm (range 3.6-6.1) in transversesection. The gastric lymph node was identified cranial and ventromedial to the pyloroduodenal angle in6 of 20 cats. It had an asymmetrical shape with a larger caudal pole in five of the six cats. The largestdimensions of the gastric lymph node were 10 mm in length, and 6 mm in width for the larger caudalpole, and 5.1 mm in width for the smaller cranial pole. Veterinary Radiology & Ultrasound, Vol. 42, No.4 , 2001, p p 330-336.Key words: ultrasonography, pancreas, cat, feline.

IntroductionISORDERS OF TH E PANCREAS are considered uncommonD n the cat. However, there is growing evidence that

pancreatitis occurs more frequently than once believed. *The ante-mortem diagnosis of feline pancreatic diseaseposes a significant challenge to the clinician because signsare often nonspecific, and blood chemistry and radiographyare considered unreliable. -3While computed axial tomog-raphy is the most useful imaging modality for pancreaticevaluation in humans, the expense, need for general anes-

From the Department of Clinical Sciences, Section of Radiology (Etue,Penninck, Pearson, Tidwell), and the Section of Medicine (Labato), FosterHospital for Small Animals, Tufts University School of Veterinary Medi-cine, North Grafton, MA 01536.Address corre spond ence and reprint requests to Dr. S.M. Etue, Depart-ment of Clinical Studies, Section of Radiology, Ontario Veterinary Col-lege, University of Guelph, Guelph, Ontario, Canada, N IG 2W l .This project was supported by a grant from the Quin by Taylor EducationFoundation.Received August 9. 2000; accepted for publication November 27, 2000.

thesia, and limited availability make it less useful in veteri-nary medicine. As a result, ultrasound is currently con-sidered the imaging modality of choice in the evaluation ofpancreatic disease in animals.436n a recent report of felinepancreatitis in four cats, one of the most significant obser-vations was the usefulness of ultrasound in detecting patho-logic changes. The ultrasonographic parameters used toevaluate canine pancreatitis have been Cur-rently, ultrasonographic evidence for pancreatitis in the dogconsists of various changes, depending on the level of in-flammation, such as pancreatic enlargement, and changes inechogenicity. Decreased echogenicity in acute pancreatitisis thought to be a result of edema and inflammatory infil-trate.6 In contrast, increased echogenicity suggests fibroticchanges.6 Extrahepatic biliary obstruction, peritoneal effu-sion, duodenal hypomotility, and increased duodenal wallthickness have also been reported to be associated withpan~reat i t is .~-~

To our knowledge, the normal ultrasonographic featuresof feline pancreatic anatomy have not been established. The

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purpose of our study was to establish the ultrasonographiccharacteristics of the feline pancreas by determining its nor-mal tissue echogenicity, structure, dimensions, and associ-ated anatomical landmarks. The reproducibility of pancre-atic measurements, and the effect of age, sex, body condi-tion, and weight were also assessed. Knowledge of thesenormal ultrasonographic features is essential for an accurateassessment of pathologic changes and can be used as areference guide for the diagnostic workup of feline pancre-atic disease.

Materials and MethodsUltrasonographic examinations were performed on 20

awake cats (1 1 neutered males and 9 neutered females)between 1 and 9 years of age with a body weight between2.7 and 7.4 kg. All cats were healthy and free of alimentarytract disease on the basis of history, physical examination,and laboratory evaluation, including: a complete bloodcount (CBC), serum biochemical analysis with serum li-pase, fibrinogen level, urinalysis, feline leukemia and felineimmunodeficiency virus testing, and toxoplasmosis titers(IgG and IgM). Each cat was assigned a body conditionscore from 1 to 9 based on published reference values forbody fat indices.'" All procedures were approved by theInstitutional Animal Care and Use Committee, Tufts Uni-versity, School of Veterinary Medicine.

Food was withheld for 12 hours prior to ultrasound ex-amination to limit the ultrasound wave propagation inter-ference with gas within the stomach and adjacent bowel.Water was available at all times. Ultrasound examinationswere performed with the cats in dorsal recumbency. Thehair was clipped from the ventral abdomen and acoustic,coupling gel was applied. All ultrasonic evaluations wereperformed using a real-time curvilinear array scanner with atransducer frequency of 8 to 5 MHz.* Real-time imageswere stored on videotape, and static images were recordedon single emulsion film using a multi-format camera.

Images of the pancreas were obtained in a manner similarto that previously described.6 Any difficulties in visualiza-tion of the pancreas were noted. The echogenicity of thepancreatic parenchyma was assessed relative to the sur-rounding mesentery, hepatic parenchyma and spleen. Theechogenicity was defined as hypoechoic, isoechoic, or hy-perechoic.

Visualization of a pancreatic duct or vessel in the left andright pancreatic lobes was recorded and confirmed by color-flow Doppler analysis. The luminal diameter of the duct orvessel in sagittal section was recorded.

Thickness measurements in millimeters for the right lobe,body, and left lobe of the pancreas were made in both the

*ATL HD I 3000, Advanced Technology Laboratories, Inc., Bothell, WA9804 .

sagittal and transverse plane using electronic calipers. Theright lobe was measured ventromedial to the right kidneyand medial to the descending duodenum. Measurements ofthe body of the pancreas were obtained directly caudal tothe pyloroduodenal angle whenever possible and medial tothe proximal descending duodenum. The left lobe was mea-sured in the region caudal to the stomach, cranial to the leftkidney, and medial to the spleen.

The diameter of the portal vein in the sagittal and trans-verse plane was recorded at the level of the pancreatic body.The mural thickness of the descending duodenum was mea-sured from the mucosal to the serosal surfaces. The dimen-sions of the duodenal papilla were recorded, when observed,in its largest left to right and dorsal to ventral axes. Thecranial abdomen was scanned at the pyloroduodenal angle,craniomedial to the pylorus for the gastric lymph node. Itsultrasonographic appearance was recorded when it was ob-served, and its measurements were recorded in the sagittalplane.

The consistency of repeated measurements was assessedby linear correlation analysis. A minimum of 3 measure-ments were obtained whenever possible, for each anatomicarea of interest, during each examination. Student's t testwas performed to assess the influence of the fixed param-eters, age, sex, body weight, and condition score, on pan-creatic dimensions. A P-value of 0.05) by differences in age, sex, body weight, or bodycondition. The body of the pancreas was not measured incats 2 or 8. Cat #2 had not been fasted and the presence offood in the stomach hampered visibility of the adjacentpancreas. Cat #8 was too fractious to allow completion of


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FIG.2. Sagittal sonographic image of th e normal left lobe of the felinepancreas. The margins of the uniformly echogenic pancreas are outlined bycursors. An ai-row points toward the pancreatic duct. S = stomach in thenear field.

FIG. I . Schematic illustration of feline pancreas drawn from a cadaverspecimen. The schematic represents a ventral view of the abdomen. Cranialis at the top of the illustration and caudal is at the bottom. GN = gastriclymph node, PV = portal vein, RK = right kidney, LK = left kidney, DD= descending duodenum, S = spleen.

the examination. A similar lack of patient cooperation pre-vented measurement of the right pancreatic lobe in cat #4.As a result, only 18 measurements of the pancreatic body,and 19 measurements of the right pancreatic lobe were ob-tained. It was not possible to obtain a minimum of 3 mea-surements for the right lobe, and pancreatic body, or for theduodenum. The left lobe of the pancreas was consistentlyeasier to locate, and a minimum of 3 measurements of theleft lobe was obtained for all 20 cats. The thickness mea-surements for the left pancreatic lobe were greater than theright lobe for every cat in the study. The thickness mea-surements for the pancreatic body were also consistentlygreater than either the right or left lobe. The pancreatic ductwas identified by its anechoic, tubular appearance with sur-rounding, thin, hyperechoic wall, and its central location(Fig. 5) . It was obse rved in all 20 cats in this study but couldonly be confirmed to be a nonvascular structure by the useof Doppler analysis (color and/or power angiography) in 17of the 20 cats. In the 3 cats for which verification could notbe established, respiratory or overall patient motion ham-pered confirmation. It was most consistently o bserv ed in theleft pancreatic lobe, (14/17 cats). The pancreatic duct was

observed and verified in the right pancreatic lobe in only 2cats (cats 5, 16). It was observed and verified in the body ofthe pancreas in 4 cats (cats 9, 12, 14, an d 17). The pancre-atic duct could be followed to the d uode nal papilla in 4 cats(Fig. 6A) . The duodenal papilla, in transverse sectionranged in size from 2.9 to 5.5 mm in width and 4.0 mm inmaximum height (Fig. 6B).

Th e pancreatic duct appeared as a tubular, anechoic struc-ture with a well-defined, thin hyperechoic wall, coursingthrough the center of the pancreatic parenchyma. It had anarrow lumen with a mean diameter of 0.8 mm (Table 1). Avascular structure within the pancreatic parenchyma wasidentified in only o ne of the cats in our study (cat 11). Boththe duct and vessel were clearly identified in the left pan-creatic lobe of this particular cat. The vessel was locatedventral to the pancreatic d uct, close to the ventral surface ofthe pancreas. While the appearance of the vessel was similarto the duct, it could be differentiated from the pancreaticduct by its eccentric position, and larger diameter of 2.1mm, (more than twice the size of the pancreatic duct).Color-flow Doppler was helpful in confirming the flowwithin the vessel.The portal vein was measured at the junction of the leftpancreatic lobe and the pancreatic body. Th e relationship tothe pancreatic body and left lobe is shown in Fig. 4. Themean diameter, including range and standard deviation islisted in Table 1 .The gastric lymph node was observed in 6 of 20 cats. All6 cats were approximately one year of age. The gastriclymp h node was located craniomedial to the pylorus. In 5 of


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FIG.3. (A) Sagittal sonographic image of the normal right lobe of thefeline pancreas. The margins of the pancreas are outlined by cursors. Theventrolateral position of the descending duodenum, wen in the near field,is helpful in localizing this lobe. Arrow points to the pancreatic duct.DUOD = descending duodenum. (B ) Transverse sonographic image of thenormal right lobe of the feline pancreas. The pancreatic parenchyma, out-lined by cursors, is poorly distinguished from the surrounding mesentericfat. The duodenum, outlined by ar rows, is a useful anatomic landmark. Thelayered wall of the duodenum is clearly seen.

the 6 cats it had an asymmetric shape with a larger caudalpole than cranial pole (Fig. 7). In the 6th cat, it had arounded appearance with no vis ible poles . The gastriclymph node in all 6 cats had a hyperechoic central regionsurrounded by a more hypoechoic outer region. Its largestdimensions were 6 mm (ventral to dorsal plane) for thelarger caudal pole, 5.1 mm (ventral to dorsal plane) fo r thesmaller cranial pole, and 10 mm (left to right axis) for itsgreatest overall length.

FIG.4. Sagittal sonographic image of the normal body of the felinepancreas at the level of the pyloroduodenal angle. The margins of thepancreas are outlined by arrows. The portal vein (PV) is seen in cross-section. ST = stomach, B = body of the pancreas, LL = left lobe ofpancreas.

DiscussionUltrasonographic evaluation of the feline pancreas can be

technically challenging. Syste matic scanning technique andknowledge of surrounding anatomic structures are impor-tant to accurate evaluation. Even with higher frequencytransducers, the margins of the pancreas are not well delin-eated from surrounding structures." This may, in part, beattributed to the similar intrinsic echogenicity of the pan-creas and surrounding fa t. Attenuation of the sound beam isalso increased in obese individuals making examination ofyoung , th in individual s ea ~ i e r . ~he interference by intralu-minal gas within the stomach and duodenum can hamperevaluation. A fluid-filled d uode num may cha nge shape withdifferential pressure and the presence of peristaltic activitymay hamper clear visualization of the right pancreatic lobe.Therefore, the quality of the examination can be improvedwith fasting. Poor patient cooperation and excessive breathmotion also are significant factors contributing to the qual-

TABLE. Measurements of the Normal Feline Pancreas and AssociatedAnatomical Landmarks

AnatomicalStructureRight lobeBodyLeft lobeDuct (S)Portal vein (T)Portal vein (S )Duo (T)Duo (S )

No . ofCats1918201719191417

Range (mm)Minimum

2.84.73. 40. 53. 62.72.22.1

Maximum5.99.59.0I .36.15.94.43.8

Mean(mni) S.D.4.5 0.876.6 1.325.4 1.460.8 0.254.5 0.614.3 0.863.0 0.692.8 0.55

S.D. = standard deviation, mm = millimeter5, T = transverse section,S = sagittal section.


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FIG. . Power D oppler sonogram. The absence of flow in the pancreaticduct in the cat is apparent. The pancreatic duct is seen as a tubular anechoicstructure with a thin, hyperechoic wall, coursing through the center of th epancreatic parenchyma. An arrow is directed toward the duct. The marginsof the left lobe of the pancreas are outlined by cursors.

ity of the ultrasonographic examination. During examina-tion of the diseased pancreas, the use of sedation, or anal-gesics may be useful to improve tolerance of the procedureand reduce patient motion.

Detailed descriptions of scanning techniques have beenpublished for the canine6,7 and feline6 pancreas. H ~ ~ ~ ~ ~ ~ ,no detailed anatomic description is avaiIable for the cat.

FIG.6 . (A ) Sagittal sonographic image of the duodenal papilla. ColorDoppler was used to confirm the absence of flow signal in the pancreaticduct. D = duodenum, DP = duodenal papilla, PV = portal vein. (B )Transverse sonographic image of the duodenal papilla (between cursors),3.7 nlm in left to right awis.Feline pancreatic anatomy can be compared to the canine

pancreas. Like the dog, the cat pancreas is divided into threeanatomic regions, which include the right lobe, left lobe,and body (Fig. 1). The right pancreatic lobe lies dorsome-dial to the descending duodenum and is united with the leftlobe at the pancreatic body.12 In contrast to the dog, thedistal third of the feline right lobe curves cranially giving ita hook-like appearan~e.'~he left lobe originates at thepancreatic body, and extends across the abdomen dorsocau-dal to the stomach and dorsocranial to the transverse co-lon.6312he distal extremity of the left lobe, in the region ofthe left kidney has a curved appearance, however to a lesserextent than the right. In comparison to the dog, the py-loroduodenal angle14 and the pancreatic body are more cen-trally located. Also in the cat, the angle formed by the leftand right lobes with the pancreatic body is smaller. Thisfinding may be partially attributed to the more acute inci-sura angularis of the feline st0ma~h.l~

In our study, the left pancreatic lobe was consistentlymore easily visualized than the right, while in the dog, theleft pancreatic lobe is less consistently identified.I6 The rea-son for this difference remains unclear, however it may be

partially attributed to the thinner size of the right pancreaticlobe in the cat compared to the left. The larger size deter-mined for the pancreatic body compared to the right and leftlobes in this study may have been overestimated by overlapof the pancreatic parenchyma where the two lobes unite(Fig. 8). Nevertheless, the measurements were highly re-peatable.

The pancreatic duct(s) arise embryonically from eitherthe dorsal or ventral bud-like duodenal primordia. Large,interlobular ducts ru n longitudinally in the middle of thepancreas, forming a common duct at about the angle of thegland, terminating in the duodenum. They may arise em-bryonically from either the dorsal or ventral, bud-likeduodenal primordia. In the cat, usually only one duct, themain pancreatic duct exists. It arises from the ventral pri-mordium and usually opens with the bile duct on the majorduodenal papilla. The major duodenal papilla is located onthe dorsal internal wall of the duodenum approximately 3cm distal to the py10rus.'~ n approximately 20% of cats asecond duct, the accessory duct, exists. It arises from the


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VOL. 42, No. 4 NORMALELINE ANCREASLTRASONOGRAPHY 335

FIG. . Normal sonographic appearance of the gastric lymph node (be-tween cursors), located craniomedial to the pyloroduodenal angle . Note theasymmetric shape seen in 5 of 6 cats; the caudal pole is larger than thecranial pole. The outer margins are hypoechoic in comparison to the hy-perechoic center. Dimensions (cursors) are 10 mm for left to right axis and4.6 mm for ventral to dorsal axis. D = duodenum, L = liver.

dorsal primordium and opens into the minor duodenal pa-pilla approximately 2 cm caudoventral to the major duode-nal papilla.'23'7318he pancreatic duct was most often ob-served i n the left pancreatic lobe and proved to be a usefullandmark for identifying pancreatic tissue. In addition, byalways assuming a central location of the duct within thepancreatic parenchyma, a more accurate determination ofthe pancreatic margins could be made, avoiding over orunder estimation of pancreatic size by tangential beamangle.

Blood supply to the pancreas is primarily from branchesof the celiac artery, which include: 1) the splenic arterysupplying the distal segment of the left lobe; 2) the gas-troduodenal artery to the body of the pancreas, and its ter-

FIG.8. Right lobe, left lobe, and body of the feline pancreas in a cadaverspecimen outlined by arrows. Note the folded appearance of the body of thepancreas where the two lobes unite. The tip of a 22 gauge needle is directedtoward the portal vein (portal v.) which crosses the body of the pancreasdorsally on its way to t h e hepatic hilus. Lt = left lobe, Rt = right lobe,D = descending duodenum.

minal branch; and 3 ) the pancreaticoduodenal artery and itsbranches which course through the parenchyma of thegland. The caudal pancreaticoduodenal branch of the cranialmesenteric artery supplies the remainder of the pan-creas.12.18.19 Various anastomoses are formed between thesevessels within the substance of the gland. Drainage occursthrough several portal tributaries, which include the cranialand caudal pancreaticoduodenal veins to the splenic andcranial mesenteric veins, r e s p e c t i ~ e l y . ' ~ ~ ' ~ ~ ~ ~n the dog, thepancreaticoduodenal artery and vein have been describedultrasonographically coursing along a longitudinal paththrough the parenchyma of the right pancreatic lobe.6393', I 6In our study, a pancreatic vessel was identified in only onecat. It was located in th e left lobe of the pancreas close to theventral surface of the pancreas. The sonographic appearanceof the pancreatic duct or vessel is similar; however, the ductis more frequently visualized in the cat, the duct's size issmaller than the vessel, and the duct's position is morecentral within the pancreatic parenchyma. Doppler analysis,however, remains the best method of differentiating thesestructures.

In our experience, the identification of the pancreas wasoften assisted by recognition of its neighboring structures.For example, localization of the duodenum was useful inidentification of the right lobe because of the close anatomi-cal association of these structures. Identification of vascularlandmarks such as the portal vein and splenic vein alsoproved very useful in localizing the feline pancreas. Theportal vein lies just dorsal to the left lobe and body of thepancreas and can be followed to the hepatic hilus. Whilescanning in the sagittal plane, the portal vein is easily iden-tified as a longitudinal vessel running parallel to, and im-mediately dorsal to the left pancreatic lobe. At the junctionof the left pancreatic lobe with the pancreatic body, how-ever, the orientation of the portal vein changes from longi-tudinal to transverse while still scanning in the sagittalplane. The pancreatic body can be localized more precisely,by observing the transverse or cross-sectional orientation ofthe portal vein during sagittal scanning of the pancreaticbody (Fig. 4) . In some cats, visualization of a large splenicvein curving around the tip of the left pancreatic lobe canalso serve as a very useful vascular landmark in identifica-tion of the pancreas (Fig. 9). The triangular window formedby the caudal edge of the stomach, the cranial aspect of theleft kidney, and medially delineated by the spleen6 is usefulin locating the splenic vein and the tip of the left lobe of thepancreas which courses ventral to it. The single, largesplenic vein is formed by the convergence of the manysplenic vein branches from the mesenteric border of th espleen.6 It follows the curvature of the stomach and can betraced to the portal vein.

A gastric lymph node was inconsistently observed in thecats of this study and has been reported to be present in-consistently in the dog and the cat.'2317,20he number of


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FIG.9. Sagittal sonographic image of the left lobe of the pancreas andthe splenic vein. The splenic vein (sp. vein) is a useful vascular landmarkas it is located dorsal to the left lobe of the pancreas in the cat. Cursorsoutline the margins of the pancreas. ST = stomach.gastric lymph nodes reported in the cat, ranges from 0 to4.l2,l7The gastric lymph node(s), when present, are locatedin the lesser omentum, close to the lesser curvature of thestomach. 2 , l 7 They receive afferent lymphatic drainagefrom the stomach, liver, esophagus, diaphragm, and perito-neum. A single gastric lymph node was observed in 6 cats

during localization of the pancreatic body. By angling thetransducer cau dal to, and slightly lateral to the gastric lymphnode, the pancreatic body could be visualized at the levelwhere the portal vein crosses it.

At the outset of this study, the mural thickness measure-ments f or the feline duodenum had not yet been established.Ultrasonographic changes reported in canine pancreati-

include increased duodenal wall thickness. It wasimportant, therefore, to establish the normal duod enal muralthickness in the cat. The mean duodenal wall thickness of2.8 mm in sagittal section and 3.0 mm in transverse sectionis slightly larger then the measure ments reported in a recentstudy of 14, healthy, awake cats.I4

In conclusion, prior knowledge of the normal pancreaticdimension, echogenicity and relationship to adjacent ana-tomical structures is essential for an accurate evaluation ofpancreatic disease. This study provides reference values forpancreatic thickness in the healthy cat, as well as the di-mensions of the pancreatic duct, duodenal wall, duodenalpapilla, portal vein, and gastric lymp h node. It is hoped thatthese data will be of value to clinicians investigating dis-eases of the feline pancreas.

tis6,9, 6

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10. Laflamme D. Development of a Body Condition Score System forCats: A Clinical Tool. Feline Practice l997;25: 13-18,11. Homco LD. Pancreas. In: Green RW. Small Animal Ultrasound.Philadelphia: Lippenc ott-Raven, 1996: 177-1 96.12. Hudson LC, Hamilton WP. Atlas of feline anatomy for veterinar-ians, 1" ed. Philadelphia: WB Saunders, 1993:287.13. Barone R. Anatomie Com paree des mammiferes domestique. Tome3, splanchnologie 1" ed. Paris: Vigot. 1997.14. Newell SM, Graham JP, Roberts GD . Ginn PE, Harrison JM . So -nography of the normal feline gastrointestinal tract. Vet Radiol and Ultra-sound 1999;40:4M3.

1.5. O'Brien TR . Pancr eas. In: Radiographic diagnosis of abdominaldisorders in the dog and cat. Philadelphia: WB Saunders, 1978:460-468.16. Lamb CR. Recent developments in diagnostic imaging of the gas-trointestinal tract of the dog and cat-progress in gastroentero logy. VetClin North Am (Small Anim Pract) 1999:307-342.17. Crouch JE. Text-atlas of cat anatomy. Philadelphia: Lea and Fe-biger, 1969:339.18. Grandage J. The pancreas. In: Slatter DH. Textbook of Small Ani-mal Surgery. Philadelphia: WB Saunders, 1985:828-853.19. Nickel R, Schummer A, Seiferle E, Sack WO. The viscera of thedomestic mammals. New York: Verlag Paul Parey, 1973:401.20. Rogers KS, Ldndis M, Barton C. Canine and feline lymph nodes.part 1. anatomy and function. Compend Contin Educ for the Pract Vet1993;15:397-409.

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