Imaging Essentials , Radiology/Imaging

Ultrasonography of the Gastrointestinal Tract: Ileum, Cecum, Colon

Ultrasonography of the Gastrointestinal Tract: Ileum, Cecum, Colon
  • 2
  •  
  •  
  •  
  •  
  •  
  •  
    2
    Shares

Elizabeth Huynh, DVM
Clifford R. Berry, DVM, DACVR University of Florida

Welcome to our series of articles on small animal abdominal ultrasonography. The initial articles provided an overview of basic ultrasonography principles and a discussion about how to perform a systematic scan of the abdomen. The rest of the series discusses ultrasound evaluation of specific abdominal organs/systems.

 

LOCALIZATION AND SCANNING TECHNIQUE

Dogs and cats are positioned in dorsal or lateral recumbency for scanning of the gastrointestinal tract. Longitudinal axis and transverse axis views of the different segments of the gastrointestinal tract are necessary for a complete examination.

Maintain a consistent sequence when evaluating the complete gastrointestinal tract; preferably, in the following order: stomach, duodenum, jejunum (see “Ultrasonography of the Gastrointestinal Tract: Stomach, Duodenum, and Jejunum” [January/February 2018]), ileum, (cecum), ileocecocolic (cat) or ileocolic (dog) junction, cecum, and parts of the colon (ascending, transverse, descending).

Ileum

The normal canine and feline ileum is short and is typically located in the right cranial to mid-quadrant of the abdominal cavity, medial to the right kidney. The ileum can be found using the transverse colon or ileo(ceco)colic junction as a guide.

The transverse colon, which is immediately caudal to the gastric body, is followed to the right of midline to the level of the ascending colon; continuing in an oral direction, bypass the ileo(ceco)colic junction to image the ileum.

The ileum is more difficult to identify in dogs than cats due to interposition of the normal gas filled cecum.

Ileocecocolic and Ileocolic Junctions

FIGURE 1. Short axis view of the transverse colon in a dog; the transverse colon is located caudal to the liver and stomach. On this sagittal image of the abdomen (cranial is to the left), note the thin walled, gas filled transverse colon with dirty acoustic shadowing.

The ileocecocolic junction (cats) or ileocolic junction (dogs) is usually located within the right cranial abdominal quadrant medial to the right kidney (FIGURES 1 AND 2).

Cecum

The canine and feline cecum is a blind sac that is medial to the descending duodenum and can usually be found caudolateral to the ileo(ceco)colic junction. Due to the superimposition of gas filled intestinal segments, the cecum is not always identifiable.

Colon

All parts of the colon are fully evaluated by beginning at the level of the ileocecocolic junction in the cat and ileocolic junction in the dog and sweeping the transducer cranially along the ascending colon. The ascending colon is a short segment of large intestine in the right cranial abdominal quadrant.

FIGURE 2. Short axis view of the caudal aspect of the descending colon in a dog. Note the thin walled (white arrowhead), gas filled descending colon with dirty acoustic shadowing. The urinary bladder is used as a landmark to find the descending colon in the far field of the image.

Continue leftwards along the transverse colon. The transverse colon spans the right to left cranial abdomen and can readily be identified using the stomach as a landmark; it is located immediately caudal to the greater curvature of the stomach (FIGURE 1). Finish scanning the colon by continuing caudally along the descending colon.

Using the urinary bladder as a landmark to identify the descending colon (FIGURE 2), a reversed approach (descending colon, transverse colon, and then ascending colon) can also be used. The descending colon, usually containing gas or feces, is located immediately dorsal to the urinary bladder, within the far field of the image.

 

 

 

BOX 1

Criteria for assessing the ileum and colon include:

  • Uniformity in diameter
  • Wall thickness (TABLE 1)
  • Discrete wall layering
  • Presence of luminal contents
  • Peristalsis

 

NORMAL ULTRASONOGRAPHIC FEATURES OF THE GASTROINTESTINAL TRACT

Canine and feline gastrointestinal wall thicknesses vary depending on the segment assessed (TABLE 1).

Ileum and Cecum

 

FIGURE 3. Short axis view of the ileum of a cat. Note the normal, prominent, hyperechoic submucosal layer (white arrowhead) and the normal, prominent, hypoechoic muscularis layer.

The ileum of cats has prominent submucosa and muscularis layers (FIGURE 3) and, due to a limited accumulation of mucus and gas, commonly has an ultrasonographically absent lumen-mucosal surface. The ileum of dogs has a prominent submucosa (FIGURE 4).

Anatomically, the ileum is contiguous to the ileocecocolic junction in the cat, leading to the ascending colon. In the dog, there is a separate ileocolic junction and cecocolic orifice.

The normally gas filled cecum has an appearance similar to a segment of normal gas filled colon. In the normal dog cecum, the wall layers of the mucosa, submucosa, and muscularis have a uniform thickness.13 Ultrasonographically, the normal feline cecum has a hypoechoic nodular inner layer (composed of multiple lymphoid follicles) and an adjacent hyperechoic submucosal layer.8 The combined mucosal and submucosal layer is referred to as the follicular layer.

FIGURE 4. Long axis view of the ileum and ileocolic junction of a dog. Note the normal, prominent, hyperechoic submucosal layer (white arrowhead).

Colon

The colon is divided into three parts: ascending, transverse, and descending. The colon typically has the thinnest wall of all intestinal segments (FIGURE 2), and the wall layering is normally indistinguishable due to distension with gas and feces. Gas and feces are seen as hyperechoic reverberation artifact with irregularly marginated, hyperechoic, partial distal acoustic shadowing material. Foreign material within the small intestines should be distinguished from gas and feces within the colon.

An empty colon may appear undulating with distinguishable layers (FIGURE 5).

ILEUM ABNORMALITIES

FIGURE 5. Long axis view of the descending colon in a dog. In this case, the colon is empty, allowing identification of both the near and far walls of the colon (calipers) at the level of the urinary bladder.

Nonneoplastic Ileal Wall Thickening

Common inflammatory diseases affecting the ileum can be found in “Ultrasonography of the Gastrointestinal Tract: Stomach, Duodenum, and Jejunum” (January/February 2018) where duodenal and jejunal wall thickening was discussed.

Malignant Ileal Neoplasms

Lymphoma is the most common intestinal neoplasm in the cat. It appears as a focal mass, multiple masses, or diffuse infiltrative neoplasia; characterized by thickening and/or loss of the normal layered appearance of the intestinal wall (FIGURE 6).9,10,14

Adenocarcinoma is the second most common intestinal neoplasm in the cat, appearing as a circumferential transmural thickening with a loss of normal intestinal layering. Predilection sites for adenocarcinoma in the cat are the jejunum and ileum.15

FIGURE 6. Long axis view of the ileocolic junction in a dog diagnosed with lymphoma (A). Note the overall thickness of the ileum (calipers), characterized by thickened submucosa and muscularis layers. There is an additional thin, hyperechoic structure traversing the mucosal layer of the ileum (white arrowhead), likely representing a region of fibrosis. Long axis view of the ileum in a cat diagnosed with lymphoma (B). Note the irregular margins, increased wall thickness (calipers), loss of wall layering, and the overall hypoechoic appearance.

Mast cell tumor is the third most common intestinal neoplasm in the cat. It more commonly involves the small intestines, including the ileum, but can involve the ileo(ceco)colic region or the colon (FIGURE 7).16,17

Sonographic abnormalities of intestinal mast cell tumors in dogs have not been widely reported.

Hemangiosarcoma is a rarely described cause of luminal narrowing in the ileum of cats.18,19

Benign Ileal Neoplasms

Leiomyoma cannot be differentiated from leiomyosarcoma using ultrasonography alone; cytologic or histopathologic diagnoses must be performed to confirm its diagnosis. Leiomyoma is uncommon in the cat.

CECUM AND COLON ABNORMALITIES

Intussusception

FIGURE 7. Short axis view of the ileocolic junction of a dog diagnosed with mast cell tumor (A). Note the irregularly marginated hypoechoic mass (calipers) circumferentially surrounding the ileal lumen (white arrowhead). Long axis view of the ileocecocolic junction of a cat diagnosed with mast cell tumor (B). Note the overall thickness of the ileum (calipers) and the thickened, hypoechoic muscularis layer.

Most intussusceptions occur in young dogs and cats and are secondary to viral, bacterial, and parasitic etiologies.

An intussusception has a multilayered appearance in longitudinal axis and concentric ring appearance in transverse axis (FIGURE 8).20-24

Intussusceptions are named according to the segments involved; enteroenteric, ileocolic, and cecocolic intussusceptions are the most common types. An ileocolic intussusception is seen within the ascending and transverse colon. A cecocolic intussusception is short and localized to the area of the cecum and proximal ascending colon. A colocolic intussusception involves the colon only.

Malignant Neoplasms

FIGURE 8. Long axis (A) and short axis (B) views of the colon of a cat diagnosed with a colocolic intussusception secondary to a colonic wall mass. Note the multilayered appearance of the colon and the hyperechoic mesentery within the center (*). The intussuscipiens (white arrows) and intussusceptum (white arrowheads) can be distinguished from one another.

Large intestinal neoplasms are not as common as small intestinal neoplasms. Adenocarcinoma25 and lymphoma are most common large intestinal tumors in cats; other large intestinal tumors include mast cell tumor and hemangiosarcoma. Adenocarcinoma and leiomyosarcoma are most common large intestinal tumors in dogs.

Intestinal adenocarcinoma affects the cecum, colon, and mid-to-distal rectum of dogs. This intestinal neoplasia appears nodular, pedunculated, and may cause annular constriction. Ultrasonographically, these neoplasms appear as circumferential transmural thickening with loss of normal intestinal layering (FIGURE 9).

FIGURE 9. Long axis view of the colon of a dog diagnosed with adenocarcinoma. Note the overall thickened wall (calipers), loss of layering, and hypoechoic appearance.

Lymphoma commonly affects the cecum and colon in dogs.

Mast cell tumors can produce focal or diffuse wall thickening of the colon of cats.16,17

Leiomyosarcomas are considered the second most common canine intestinal tumor and the most common intestinal sarcoma in dogs.26 Leiomyosarcoma causes large, eccentrically located, single or multiple, hypoechoic or anechoic area(s) of wall thickening.27 They have a low incidence of developing in the cecum and colon (FIGURE 10).28

Leiomyosarcoma is uncommon in the cat.

Hemangiosarcoma causes luminal narrowing and has been identified in the colon and rectum of cats.18,19

FIGURE 10. Long axis view of the colon of a dog diagnosed with a colonic leiomyosarcoma. Note the pedunculated, heterogeneous, eccentrically located mass associated with the wall of the colon (calipers).

Gastrointestinal stromal tumors arise from the interstitial cells of Cajal; these are cells that regulate intestinal motility and peristalsis. They have histologic features similar to that of intestinal smooth muscle tumors but can be distinguished by immunohistochemistry.29 The predilection sites for these tumors are the cecum and colon, whereas, smooth muscle tumors are more likely to be affect the stomach and small intestine.29

Gastrointestinal stromal tumor has been described in the feline jejunum as a hypoechoic mass with heterogeneous regions.30

Benign Neoplasms

Adenomatous polyps are infrequently seen lesions that have been identified in the rectum of dogs and small intestines of cats.15,25 They appear as small, round to ovoid, mixed or varying echogenicity, pedunculated or broad based structures extending into the intestinal lumen; they can arise from the mucosal or submucosal surfaces.31-34There is a great potential for malignant transformation if they are large (FIGURE 11).

FIGURE 11. Long axis view of the descending colon and rectum of a dog diagnosed with an adenomatous polyp. Secondary to the mass protruding into the colonic lumen, note the focal thickening, loss of wall layering, and distortion of the hyperechoic gas interface.

Nonneoplastic Wall Thickening

Nonmalignant diseases, such as histiocytic,35 granulomatous,36 and fungal37 colitis, can cause focal wall thickening or masses.

Eosinophilic sclerosing fibroplasia has been described in the ileocecocolic junction and the colon of cats (FIGURE 12);38,39 these lesions appear as masses or focal wall thickening with a loss of normal wall layering, similar to neoplastic lesions.39

Pythiosis can cause multifocal pyogranulomatous infections of the colon, causing focal wall thickening with a loss of wall layering, although an eccentric colonic mural mass was identified in one dog.40

Common intestinal inflammatory bowel diseases, such as lymphocytic-plasmacytic enteritis, are usually associated with mild to moderate wall thickening, affecting several or all intestinal segments with variable severity.35,36 Other ultrasonographic features of intestinal inflammatory diseases include symmetric, mild to moderate wall thickening, affecting primarily the mucosa, submucosa, and/or muscularis layer; diffuse increased echogenicity of the mucosa; or presence of bright mucosal speckles (FIGURE 13).41,42

FIGURE 12. Short axis view of the ileum of a cat diagnosed with eosinophilic sclerosing fibroplasia. Note the circumferential thickening of the muscularis layer (white arrowhead) of the ileum.

In severe cases of colitis, the wall layering may be altered or lost. Additionally, micronodular, submucosal hypoechoic and/or anechoic lesions measuring 1 to 3 mm in diameter, representing intraparietal lymphoid follicles, may be present in dogs and cats with inflammatory bowel disease.43

Differentiation between colitis and large intestinal infiltrative neoplasia may be difficult;44 however, according to recent literature, dogs with intestinal tumors had significantly greater wall thickness, loss of wall layering, and more focal lesions than dogs with enteritis.42 Ultimately, histopathology is required to differentiate between colitis and infiltrative neoplasia.44

SUMMARY

FIGURE 13. Long axis view of the colon of a cat diagnosed with severe pyogranulomatous colitis (A). Note the thickened wall and loss of wall layering. In cases with severe colitis, ultrasonographic appearances are indistinguishable from neoplastic infiltration. Long axis view of the colon of a dog diagnosed with epithelial hyperplasia and neutrophilic inflammation of the colon (B). Note the thickened but preserved layering of the wall.

Common ultrasonographic abnormalities of the dog and cat gastrointestinal tract may have neoplastic or nonneoplastic etiologies and, once identified, may require further diagnostics for definitive diagnosis. A systematic examination of the gastrointestinal tract is a routine part of the complete abdominal evaluation.

References

  1. Penninck DG, Nyland TG, Fisher PE, Kerr LY. Ultrasonography of the normal canine gastrointestinal tract. Vet Radiol Ultrasound 1989;30(6):272-276.
  2. Newell SM, Graham JP, Roberts GD, et al. Sonography of the normal feline gastrointestinal tract. Vet Radiol Ultrasound 1999;40(1):40-43.
  3. Goggin JM, Biller DS, Debey BM, et al. Ultrasonographic measurement of gastrointestinal wall thickness and the ultrasonographic appearance of the ileocolic region in healthy cats. J Am Anim Hosp Assoc 2000;36(3):224-228.
  4. Stander N, Wagner WM, Goddard A, Kirberger RM. Normal canine pediatric gastrointestinal ultrasonography. Vet Radiol Ultrasound 2010;51(1):75-78.
  5. Penninck DG, d’Anjou M. Atlas of Small Animal Ultrasonography. 2nd ed. Ames: Wiley Blackwell; 2015.
  6. Di Donato P, Penninck D, Pietra M, et al. Ultrasonographic measurement of the relative thickness of intestinal wall layers in clinically healthy cats. J Feline Med Surg 2014;16(4):333-339.
  7. Larson MM, Biller DS. Ultrasound of the Gastrointestinal Tract. Vet Clin North Am: Small Anim Pract 2009;39:747-759.
  8. Hahn H, Pey P, Baril A, et al. Ultrasonographic, endoscopic and histological appearances of the caecum in cats presenting with chronic clinical signs of caecocolic disease. J Feline Med Surg 2017;19(2):94-104.
  9. Mahony OM, Moore AS, Cotter SM, et al. Alimentary lymphoma in cats: 28 cases (1988-1993). JAVMA 1995;207(12):1593-1598.
  10. Penninck DG, Moore AS, Tidwell AS, et al. Ultrasonography of alimentary lymphosarcoma in the cat. Vet Radiol Ultrasound 1994;35(4):299-306.
  11. Gladwin NE, Penninck DG, Webster CR. Ultrasonographic evaluation of the thickness of the wall layers in the intestinal tract of dogs. Am J Vet Res 2014;75(4):349-353.
  12. Winter MD, Londono L, Berry CR, Hernandez JA. Ultrasonographic evaluation of relative gastrointestinal layer thickness in cats without clinical evidence of gastrointestinal tract disease. J Feline Med Surg 2014;16(2):118-124.
  13. Besso JG, Rault D, Begon D. Feline cecum and ileocecocolic junction: normal ultrasonographic features and clinical applications (abstract). Vet Radiol Ultrasound 2004;45:599.
  14. Grooters AM, Biller DS, Ward H, et al. Ultrasonographic appearance of feline alimentary lymphoma. Vet Radiol Ultrasound 1994;35(6):468-472.
  15. Tams TR. Handbook of Small Animal Gastroenterology. 2nd ed. St. Louis: Saunders; 2003.
  16. Sato AF, Solano M. Ultrasonographic findings in abdominal mast cell disease: a retrospective study of 19 patients. Vet Radiol Ultrasound 2004;45(1):51-57.
  17. Laurenson MP, Skorupski KA, Moore PF, Zwingenberger AL. Ultrasonography of intestinal mast cell tumors in the cat. Vet Radiol Ultrasound 2011;52(3):330-334.
  18. Sharpe A, Cannon MJ, Lucke VM, Day MJ. Intestinal haemangiosarcoma in the cat: clinical and pathological features of four cases. J Small Anim Pract 2000;41(9):411-415.
  19. Culp WT, Drobatz KJ, Glassman MM, et al. Feline visceral hemangiosarcoma. J Vet Intern Med 2008;22(1):148-152.
  20. Penninck DG, Nyland TG, Kerr LY, Fisher PE. Ultrasonographic Evaluation of Gastrointestinal-Diseases in Small Animals. Vet Radiol Ultrasound 1990;31(3):134-141.
  21. Larson MM, Biller DS. Ultrasound of the gastrointestinal tract. Vet Clin North Am Small Anim Pract 2009;39(4):747-759.
  22. Garcia DA, Froes TR, Vilani RG, et al. Ultrasonography of small intestinal obstructions: a contemporary approach. J Small Anim Pract 2011;52(9):484-490.
  23. Patsikas MN, Papazoglou LG, Papaioannou NG, et al. Ultrasonographic findings of intestinal intussusception in seven cats. J Feline Med Surg 2003;5(6):335-343.
  24. Patsikas MN, Jakovljevic S, Moustardas N, et al. Ultrasonographic signs of intestinal intussusception associated with acute enteritis or gastroenteritis in 19 young dogs. J Am Anim Hosp Assoc 2003;39(1):57-66.
  25. Rissetto K, Villamil JA, Selting KA, et al. Recent trends in feline intestinal neoplasia: an epidemiologic study of 1,129 cases in the veterinary medical database from 1964 to 2004. J Am Anim Hosp Assoc 2011;47(1):28-36.
  26. Cohen M, Post GS, Wright JC. Gastrointestinal leiomyosarcoma in 14 dogs. J Vet Intern Med 2003;17(1):107-110.
  27. Myers NC, Penninck DG. Ultrasonographic diagnosis of gastrointestinal smooth-muscle tumors in the dog. Vet Radiol Ultrasound 1994;35(5):391-397.
  28. Beck C, Slocombe RF, O’Neill T, Holloway SA. The use of ultrasound in the investigation of gastric carcinoma in a dog. Aust Vet J 2001;79(5):332-334.
  29. Frost D, Lasota J, Miettinen M. Gastrointestinal stromal tumors and leiomyomas in the dog: a histopathologic, immunohistochemical, and molecular genetic study of 50 cases. Vet Pathol 2003;40(1):42-54.
  30. Suwa A, Shimoda T. Intestinal gastrointestinal stromal tumor in a cat. J Vet Med Sci 2017;79(3):562-566.
  31. Diana A, Penninck DG, Keating JH. Ultrasonographic appearance of canine gastric polyps. Vet Radiol Ultrasound 2009;50(2):201-204.
  32. Castillo-Alcala F, Mans C, Bos AS, et al. Clinical and pathologic features of an adenomatous polyp of the colon in a domestic ferret (Mustela putorius furo). Can Vet J 2010;51(11):1261-1264.
  33. Bemelmans I, Kury S, Albaric O, et al. Colorectal hamartomatous polyposis and ganglioneuromatosis in a dog. Vet Pathol 2011;48(5):1012-1015.
  34. Daure E, Jania R, Jennings S, et al. Ultrasonographic and clinicopathological features of pyloroduodenal adenomatous polyps in cats. J Feline Med Surg 2017;19(2):141-145.
  35. Hostutler RA, Luria BJ, Johnson SE, et al. Antibiotic-responsive histiocytic ulcerative colitis in 9 dogs. J Vet Intern Med 2004;18(4):499-504.
  36. Manchester AC, Hill S, Sabatino B, et al. Association between granulomatous colitis in French bulldogs and invasive Escherichia coli and response to fluoroquinolone antimicrobials. J Vet Intern Med 2013;27(1):56-61.
  37. Schumacher LL, Love BC, Ferrell M, et al. Canine intestinal histoplasmosis containing hyphal forms. J Vet Diagn Invest 2013;25(2):304-307.
  38. Linton M, Nimmo JS, Norris JM, et al. Feline gastrointestinal eosinophilic sclerosing fibroplasia: 13 cases and review of an emerging clinical entity. J Feline Med Surg 2015;17(5):392-404.
  39. Weissman A, Penninck D, Webster C, et al. Ultrasonographic and clinicopathological features of feline gastrointestinal eosinophilic sclerosing fibroplasia in four cats. J Feline Med Surg 2013;15(2):148-154.
  40. Graham JP, Newell SM, Roberts GD, Lester NV. Ultrasonographic features of canine gastrointestinal pythiosis. Vet Radiol Ultrasound 2000;41(3):273-277.
  41. Baez JL, Hendrick MJ, Walker LM, Washabau RJ. Radiographic, ultrasonographic, and endoscopic findings in cats with inflammatory bowel disease of the stomach and small intestine: 33 cases (1990-1997). JAVMA 1999;215(3):349-354.
  42. Penninck D, Smyers B, Webster CR, et al. Diagnostic value of ultrasonography in differentiating enteritis from intestinal neoplasia in dogs. Vet Radiol Ultrasound 2003;44(5):570-575.
  43. Citi S, Chimenti T, Marchetti V, et al. Micronodular ultrasound lesions in the colonic submucosa of 42 dogs and 14 cats. Vet Radiol Ultrasound 2013;54(6):646-651.
  44. Carrasco V, Rodriguez-Bertos A, Rodriguez-Franco F, et al. Distinguishing intestinal lymphoma from inflammatory bowel disease in canine duodenal endoscopic biopsy samples. Vet Pathol 2015;52(4):668-675.
Elizabeth Huynh
Elizabeth Huynh, DVM, is a diagnostic imaging resident and graduate student at University of Florida College of Veterinary Medicine. Her interests include ultrasonography, cross-sectional imaging, and nuclear medicine. She received her DVM from Ross University, finished her clinical year at Ohio State University, and completed a diagnostic imaging internship at Animal Specialty and Emergency Center in Los Angeles, California.
Clifford R. Berry
Clifford R. Berry, DVM, DACVR, is a professor of diagnostic imaging at University of Florida College of Veterinary Medicine. His research interests include cross-sectional imaging of the thorax, nuclear medicine, and biomedical applications of imaging. He received his DVM from University of Florida and completed a radiology residency at University of California–Davis.

DMCA.com Protection Status
[gravityform id="6" title="false" description="false"]
<div class='gf_browser_unknown gform_wrapper' id='gform_wrapper_6' style='display:none'><form method='post' enctype='multipart/form-data' id='gform_6' action='/imaging-essentials-ultrasonography-of-the-gastrointestinal-tract-ileum-cecum-colon/'> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_1' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_1'> <span id='input_6_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_6_1_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_3' >First</label> </span> <span id='input_6_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_6_1_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_1_6' >Last</label> </span> </div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_6_2' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_7' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_7' >Profession / Role<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Veterinarian' >Veterinarian</option><option value='Veterinary Nurse / Technician' >Veterinary Nurse / Technician</option><option value='Practice Manager / Veterinary Assistant / Support Staff' >Practice Manager / Veterinary Assistant / Support Staff</option><option value='Student (Veterinarian or Veterinary Nurse)' >Student (Veterinarian or Veterinary Nurse)</option><option value='Other' >Other</option></select></div></li><li id='field_6_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_15' class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' >Inbox Preferences</label><div class='gfield_description' id='gfield_description_6_15'>Customize your inbox by selecting the areas you are most interested in. </div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='NAVC Better Care Weekly&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.&lt;/div&gt;' checked='checked' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>NAVC Better Care Weekly<br><div style="font-size: 12px; color: #808080;">A weekly roundup of the new and noteworthy innovations and educational opportunities in the veterinary industry.</div></label> </li><li class='gchoice_6_15_2'> <input name='input_15.2' type='checkbox' value='Today&#039;s Veterinary Business eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.&lt;/div&gt;' id='choice_6_15_2' /> <label for='choice_6_15_2' id='label_6_15_2'>Today's Veterinary Business eNewsletter<br><div style="font-size: 12px; color: #808080;">Covers topics relating to practice management, financial metrics, marketing, retailing and merchandising, and industry news.</div></label> </li><li class='gchoice_6_15_3'> <input name='input_15.3' type='checkbox' value='Today&#039;s Veterinary Nurse eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.&lt;/div&gt;' id='choice_6_15_3' /> <label for='choice_6_15_3' id='label_6_15_3'>Today's Veterinary Nurse eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed companion animal educational CE for veterinary nurses, technicians and assistants.</div></label> </li><li class='gchoice_6_15_4'> <input name='input_15.4' type='checkbox' value='Today&#039;s Veterinary Practice eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.&lt;/div&gt;' id='choice_6_15_4' /> <label for='choice_6_15_4' id='label_6_15_4'>Today's Veterinary Practice eNewsletter<br><div style="font-size: 12px; color: #808080;">Provides practical, peer-reviewed articles focused on the latest diagnostic and treatment techniques to enhance your knowledge and confidence.</div></label> </li><li class='gchoice_6_15_5'> <input name='input_15.5' type='checkbox' value='VetFolio eNewsletter&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.&lt;/div&gt;' id='choice_6_15_5' /> <label for='choice_6_15_5' id='label_6_15_5'>VetFolio eNewsletter<br><div style="font-size: 12px; color: #808080;">Discover online CE resources offered in a variety of formats including videos, podcasts, webinars and more.</div></label> </li><li class='gchoice_6_15_6'> <input name='input_15.6' type='checkbox' value='Partner Emails&lt;br&gt;&lt;div style=&quot;font-size: 12px;color: #808080&quot;&gt;Exclusive deals and information from our partners.&lt;/div&gt;' id='choice_6_15_6' /> <label for='choice_6_15_6' id='label_6_15_6'>Partner Emails<br><div style="font-size: 12px; color: #808080;">Exclusive deals and information from our partners.</div></label> </li></ul></div></li><li id='field_6_19' class='gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible' ><br></li><li id='field_6_22' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' >Do you want to be added to our postal mailing list?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_22'><li class='gchoice_6_22_1'> <input name='input_22.1' type='checkbox' value='Yes, I love mail!' id='choice_6_22_1' /> <label for='choice_6_22_1' id='label_6_22_1'>Yes, I love mail!</label> </li><li class='gchoice_6_22_2'> <input name='input_22.2' type='checkbox' value='No thank you.' id='choice_6_22_2' /> <label for='choice_6_22_2' id='label_6_22_2'>No thank you.</label> </li></ul></div></li><li id='field_6_10' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Please provide your mailing address below.<span class='gfield_required'>*</span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_10' > <span class='ginput_full address_line_1' id='input_6_10_1_container' > <input type='text' name='input_10.1' id='input_6_10_1' value='' aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div><script type='text/javascript'> jQuery(document).bind('gform_post_render', function(event, formId, currentPage){if(formId == 6) {gf_global["number_formats"][6] = {"1":{"price":false,"value":false},"2":{"price":false,"value":false},"7":{"price":false,"value":false},"20":{"price":false,"value":false},"15":{"price":false,"value":false},"19":{"price":false,"value":false},"22":{"price":false,"value":false},"10":{"price":false,"value":false}};if(window['jQuery']){if(!window['gf_form_conditional_logic'])window['gf_form_conditional_logic'] = new Array();window['gf_form_conditional_logic'][6] = { logic: { 10: {"field":{"actionType":"show","logicType":"any","rules":[{"fieldId":"22","operator":"is","value":"Yes, I love mail!"}]},"nextButton":null,"section":null} }, dependents: { 10: [10] }, animation: 1, defaults: {"1":{"1.2":"","1.3":"","1.4":"","1.6":"","1.8":""},"15":["choice_6_15_1"],"10":{"10.1":"","10.2":"","10.3":"","10.4":"","10.5":"","10.6":""}}, fields: {"1":[],"2":[],"7":[],"20":[],"15":[],"19":[],"22":[10],"10":[]} }; if(!window['gf_number_format'])window['gf_number_format'] = 'decimal_dot';jQuery(document).ready(function(){gf_apply_rules(6, [10], true);jQuery('#gform_wrapper_6').show();jQuery(document).trigger('gform_post_conditional_logic', [6, null, true]);} );} gformInitChosenFields('#input_6_7','No results matched');} } );jQuery(document).bind('gform_post_conditional_logic', function(event, formId, fields, isInit){gformInitChosenFields('#input_6_7','No results matched');} );</script><script type='text/javascript'> jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [6, 1]) } ); </script>
MENU