ULTRASONOGRAPHIC EVALUATION OF ADRENAL GLAND SIZE

COMPARED TO BODY WEIGHT IN NORMAL DOGS

STACY N. SOULSBY, MERRILEE HOLLAND, JUDITH A. HUDSON, ELLEN N. BEHREND

The accepted cut-off value for adrenal gland maximum diameter of 0.74 cm to distinguish adrenal gland
enlargement in dogs regardless of body weight may not be appropriate for small to medium breed dogs. The
purpose of the current retrospective study was to examine adrenal gland dimensions as a function of body weight
in healthy dogs in three weight categories (< 10 kg, 10–30 kg, and > 30 kg) representing small, medium, and
large breeds, respectively, to establish greater confidence in determining if adrenal gland size is abnormal. The
measurements of length (sagittal plane), cranial and caudal pole thickness (sagittal and transverse planes), and
caudal pole width (transverse plane) of both adrenal glands were obtained ultrasonographically in clinically
healthy dogs (n = 45) with 15 dogs in each weight group. Findings support our hypothesis that adrenal gland size
correlates with body weight in normal dogs, and more precise reference intervals should be created for adrenal
gland size by categorizing dogs as small, medium, or large breed. The caudal pole thickness of either adrenal
gland in a sagittal plane was the best dimension for evaluating adrenal gland size based on low variability, ease,
and reliability in measurement.  C 2014 American College of Veterinary Radiology.

Key words: adrenal gland, body weight, dog, ultrasound.

Introduction have been reported to vary from 0.91 to 5.02 cm for

length,2–15 from 0.19 to 1.74 cm for width,2–12 and from 0.17
A PRELIMINARY DIAGNOSIS OF hyperadrenocorticism
is made based on the history, physical examination
findings, and analysis of routine blood tests and urinaly-
to 1.07 cm for thickness/height.3–6,8,9,13–18 Additionally, al-
though dogs with hyperadrenocorticism have adrenal gland
measurements significantly greater than those of normal
sis, while specific endocrine tests are used to confirm the
dogs4,5,10,11,15–17 and dogs with hypoadrenocorticism have
diagnosis. Although no endocrine test used to screen for
adrenal gland measurements significantly less than those of
hyperadrenocorticism is perfectly accurate, the sensitivi-
normal dogs,13,14 an overlap in the range of measurements
ties and specificities are quite high.1 Thus, ultrasonog-
of dogs with either disease and normal dogs is present.
raphy is commonly used as a means of supporting a
The overlap may be a result of a body weight-associated
diagnosis of hyperadrenocorticism and in aiding in
variation in measurements of normal adrenal glands.
differentiation of pituitary-dependent hyperadrenocorti-
Whether or not a relationship exists between ultra-
cism (PDH) from adrenal-dependent hyperadrenocorti-
sonographically obtained adrenal gland measurements and
cism (ADH). Ultrasonography is not flawless, as dogs
body weight has not been clearly documented in pre-
with hyperadrenocorticism may have adrenal glands which
vious reports. Discrepancies exist among earlier stud-
are symmetrically or asymmetrically enlarged or normal-
ies that attempted to document an association between
sized.1 However, it is the preferred imaging modality in
adrenal gland measurements and body weight using
evaluating adrenal glands in veterinary medicine.
ultrasonography,3–5,7,8,11,12,16,17 but Bertolini et al. found no
A wide range of values have been documented by previ-
relationship between the volume of the adrenal glands and
ous studies with regard to normal ultrasonographic size
body weight using computed tomography.19
(length, width, and thickness) of the adrenal glands in
The terminology used in prior studies to describe the
healthy dogs. Adrenal gland measurements in normal dogs
maximum diameter of the caudal pole of the adrenal gland
as measured in a sagittal plane ultrasonographically can
From the Department of Clinical Sciences, Auburn University Col-
lege of Veterinary Medicine, Auburn, AL, 36849-5540. be confusing since previous researchers have chosen to
Address correspondence and reprint requests to Stacy N. Soulsby, define this dimension as either height,3 width,5,7,11,12 or
at Diagnostic Imaging, P.C., 22020 E. Arbor Drive, Aurora, CO 80016. thickness.8,16,17 Table 1 summarizes earlier studies which
E-mail: snsoulsby@gmail.com.
have used ultrasonography to evaluate adrenal gland size
Received January 23, 2014; accepted for publication November 4,
2014. and shows what each study labeled as the maximum
doi: 10.1111/vru.12236 dorsoventral dimension of the caudal pole of the adrenal
Vet Radiol Ultrasound, Vol. 00, No. 0, 2014, pp 1–10. gland in a sagittal plane, if a correlation with body weight

1
2 SOULSBY ET AL. 2014

TABLE 1. Summary of Findings from Previous Ultrasonographic Studies Examining the Maximum Dorsoventral Thickness of the Caudal Pole of the
Adrenal Gland in a Sagittal Plane and its Correlation with Body Weight in Healthy Dogs

Name Given to Maximum Suggested Upper Threshold for Maximum Correlation Found with
Dorsoventral Dimension of the Dorsoventral Measurement of the Maximum Dorsoventral
Previous Caudal Pole of the Adrenal Caudal Pole of the Adrenal Diameter and Body
Study Gland in a Sagittal Plane Gland in a Sagittal Plane (cm) Weight
de Chalus et al.3 Height Left – 0.54 Right – 0.67 Yes
(23 dogs 1.9 – 4.1 kg) (23 dogs 1.9 – 4.1 kg)
Left – 0.79 Right – 0.95
(17 dogs 26.8 – 38.6 kg) (17 dogs 26.8 – 38.6 kg)

Barthez et al.5 Maximum Diameter /
Width ∗
Douglass et al.7 Width
Left – 0.74∗ Right – 0.81∗ No (Correlation with
(20 dogs 4.4 – 38.8 kg) (20 dogs 4.4 – 38.8 kg) Length and Body
Weight)
No upper threshold reported No (Correlation with
Length and Body
Weight)

Grooters et al.8 Thickness Left – 0.50 Right – 0.50 Yes

(14 dogs 13.6 – 20.3 kg) (14 dogs 13.6 – 20.3 kg)

Choi et al.11 Width Left – 0.60 Right – 0.60 Yes

(175 dogs 0.84 – 10.0 kg) (80 dogs 0.84 – 10.0 kg)

Mogicato et al.12 Width No upper threshold reported No (Correlation with

Length and Body
Weight)

Grooters et al.16 Thickness Left – 0.70 Right – 0.70 Yes

(10 dogs 9.1 – 38.6 kg) (10 dogs 9.1 – 38.6 kg)

De Marco et al.17 Thickness Left or Right – 0.59 (109 dogs ࣘ 10 kg) Yes

∗
Measured in a transverse plane.
cm, centimeters; kg, kilograms.

was identified with this dimension, and if body weight
played a role. To minimize readers’ misunderstanding of
the terminology used in this and previous manuscripts,
the authors have decided to define “length” as the max-
imum craniocaudal dimension measured in the sagittal
plane, “thickness” as the maximum dorsoventral dimension
measured in the sagittal or transverse plane, and “width”
as the maximum mediolateral dimension measured in the
transverse plane. To maintain consistency, the authors of
this manuscript have chosen to use the terms as described
above throughout the remainder of this manuscript re-
gardless of how that term was used in the original pa-
per. Table 1 shows three studies found a correlation only
between adrenal gland length and body weight.5,7,12 How-
ever, two other studies suggested an association may ex-
ist between animal size and adrenal gland thickness, as
adrenal gland thickness was significantly different between
normal medium and large-sized dogs.8,16 More recent stud-
ies have detected a relationship between body weight and
the thickness of the caudal pole of the adrenal gland in
a sagittal plane when small breed dogs (< 10 kg) were
examined.11,17 Cut-off values of 0.60 cm11 and 0.59 cm17
were proposed for distinguishing normal adrenal glands
from adrenal hyperplasia due to PDH. A third study by
de Chalus et al. found a correlation between thickness of
the caudal pole of the adrenal gland in a sagittal plane and
breed. They suggested an upper threshold of 0.54 cm and
0.67 cm for the thickness of left and right adrenal glands,
respectively, in Yorkshire terriers and 0.79 cm and 0.95 cm,
respectively, in Labrador retrievers.3 These proposed cut-
offs contradict the most accepted parameter for ultrasono-
graphic assessment of the size of canine adrenal glands. The
most commonly used parameter provides a single cut-off
value of 0.74 cm for normal adrenal gland thickness of the
larger of the cranial or the caudal pole in either a sagit-
tal or transverse plane regardless of body weight for the
diagnosis of PDH (sensitivity of 77% and a specificity of
80%).5,6
Grooters et al. determined that ultrasonographically
measured adrenal gland thickness, but not adrenal gland
length or width, accurately represents gross measurements8
while independently, Barberet et al. noted that measure-
ments of adrenal gland thickness at the caudal pole
in a sagittal plane have the least intraobserver and in-
terobserver variability.9 Therefore, since dogs have great
variability in body weight and previous studies have not
VOL. 00, NO. 0 US EVALUATION OF ADRENAL GLAND SIZE IN DOGS
consistently identified a single best measurement for dis-
tinguishing normal from enlarged adrenal glands, further
research is needed to determine if a relationship exists be-
tween adrenal gland size (length, width, and thickness) in
small, medium, and large breed dogs.
To the investigators’ knowledge, no studies have been
performed in which dogs have been divided into multiple
groups based on their body weight for ultrasonographic
evaluation of adrenal gland dimensions in an effort to pro-
vide reference ranges for normal adrenal gland size in vari-
ous weight categories. Therefore, the aim of this study was
to use ultrasonography in healthy dogs to determine if a
relationship exists between adrenal gland dimensions and
body weight. We hypothesized there would be a difference
in adrenal gland measurements based on body weight. The
ultimate goal of this study was to establish more precise
reference intervals for adrenal size in three different weight
categories of dogs.
Materials and Methods
This prospective study was conducted in accordance
with requirements of the Auburn University Institutional
Animal Care and Use Committee. Forty-six dogs belong-
ing to students, staff, and faculty of the Auburn University
College of Veterinary Medicine were recruited for partic-
ipation. Inclusion criteria were as follows: (1) age between
1 and 6 years; (2) body condition score of 2 to 6 out of 9;
and (3) a negative occult heartworm test within the past
year and heartworm prevention administration for at least
6 consecutive months prior to the start of the study. All
dogs were fasted for 12 h prior to participation. A physical
examination, complete blood count, serum biochemistry
panel, and urinalysis obtained via cystocentesis were per-
formed on each dog to establish apparent health. During
the physical examination, each dog was weighed and the
body condition score was assessed. Exclusion criteria were
as follows: (1) the presence of clinical signs, physical ex-
amination findings, or laboratory abnormalities consistent
with hyperadrenocorticism (e.g. polyphagia, polydipsia,
polyuria, pot-bellied appearance, hepatomegaly, alopecia,
pyoderma, or skin hyperpigmentation) or hypoadrenocor-
ticism (e.g. anorexia, vomiting, diarrhea, or weight loss);
(2) the presence of chronic medical conditions (e.g. adrenal,
renal/urinary, liver, heartworm, respiratory, or cardiac
disease, diabetes mellitus, or hypothyroidism); or (3) ad-
ministration of any medications (including topical or otic
preparations containing corticosteroids, but excluding
monthly flea/tick and heartworm prevention) during the
2 months prior to the study.
All ultrasonographic examinations were performed us-
ing either an 8–5 MHz or a 5–2 MHz electric curved ar-
ray transducer and a Philips iE33 xMATRIX Ultrasound
3
System (Philips Medical Systems, Eindhoven, The Nether-
lands). Dogs were manually restrained in lateral recum-
bency, hair was clipped from the abdomen dorsal to the
level of the transverse processes of the lumbar spine and
cranial to the level of the last few intercostal spaces, a
liberal amount of coupling gel was applied to the shaved
portion of the abdomen, and dogs and were scanned us-
ing a previously described ultrasound protocol6,20 to ex-
amine the entire abdomen with particular emphasis being
placed on the adrenal glands. The initial abdominal ul-
trasound examination and measurements was performed
by a second-year radiology resident (S.N.S) under the su-
pervision of a board-certified radiologist (M.H.). The ab-
dominal ultrasound examination and measurements were
repeated by another board-certified radiologist (J.A.H.)
later in the day with each observer unaware of the other’s
measurements.
The adrenal glands were imaged in two standard planes,
sagittal and transverse, preferentially positioning the
transducer caudal to the ribs and scanning subcostal rather
than intercostal. The sagittal plane was defined as the long
axis of the adrenal gland, which approximated the sagittal
plane of the body, in which the adrenal gland length
and thickness were both maximal. From this plane, the
maximal length (craniocaudal dimension) of the adrenal
gland and the maximal thickness of the cranial and caudal
poles (dorsoventral dimension) of the adrenal gland were
measured with electronic calipers (Figs. 1 and 2). The
transverse plane was defined as the short axis of the adrenal
gland obtained by rotating the probe 90o from the sagittal
plane at the caudal pole of the adrenal gland. From the
transverse plane, the maximal thickness of the caudal pole
(dorsoventral dimension) and the maximal width of the
caudal pole (mediolateral dimension) of the adrenal gland
were measured with electronic calipers. Each measurement
was obtained three times by both sonographers (S.N.S. and
J.A.H). The process was repeated for the opposite adrenal
gland.
Statistical tests were selected and performed by a board-
certified veterinarian in preventative medicine and profes-
sor of pathobiology at the Auburn University College of
Veterinary Medicine who has teaching and research inter-
ests in epidemiology (J.C.W.). Intraobserver, interobserver,
and side (left and right adrenal gland) variability were
evaluated as random factors in a mixed model, analysis of
variance (ANOVA) to assess repeatability and reproducibil-
ity of the measurements. The reproducibility was further
evaluated by calculating a coefficient of variation for
each of the adrenal gland measurements. Ultimately, each
measurement between the two observers were pooled and
averaged because there were no intraobserver differences
or side (left and right adrenal gland) differences when the
statistics were analyzed for each observer independently of
the other observer. In addition, the minimal interobserver
4 SOULSBY ET AL. 2014

FIG. 1. Ultrasound images illustrating measuring the left adrenal gland with the patient in right lateral recumbency. (A) Electronic calipers measuring the
length and the thickness of the cranial and caudal poles of the adrenal gland are displayed in the sagittal plane. (B) Electronic calipers measuring the thickness
and width of the caudal pole of the adrenal gland are displayed in the transverse plane.

FIG. 2. Ultrasound images illustrating measuring the right adrenal gland with the patient in left lateral recumbency. (A) Electronic calipers measuring the
length and the thickness of the cranial and caudal poles of the adrenal gland are displayed in the sagittal plane. (B) Electronic calipers measuring the thickness
and width of the caudal pole of the adrenal gland are displayed in the transverse plane.

and side differences found when the data were pooled were
deemed not to be clinically significant for reasons explained
later in the text. The range, mean, and standard deviation
of each measurement (length of the adrenal gland and
thickness of the cranial and caudal poles of the adrenal
gland in the sagittal plane and width and thickness of the
caudal pole of the adrenal gland in the transverse plane)
were calculated for each dog for the adrenal glands. A
mixed model, ANOVA was also used to compare measure-
ments between the three body weight groups. Correlation
between each measurement of the adrenal glands and body
weight were assessed using a Pearson’s test for each of the
three body weight groups. The correlations were qualified
using the following scale: r = 0 – 0.30, r = 0.31 – 0.70,
and r ࣙ 0.71 were mild, moderate, or a strong correlation,
respectively. Data were analyzed with statistical analysis
systems (SASTR release version 9.1, Cary, N.C.) software.
Significance was set at the P < 0.05 level.
Results
Of the original 46 dogs that met the inclusion criteria
and were screened, one dog was found to have a urinary
tract infection and was removed from the study. The re-
maining 45 dogs were divided by body weight into one of
three groups (< 10 kg, 10–30 kg, and > 30 kg), with 15
dogs in each group, representing small, medium, and large
breed sizes of dogs, respectively. The weights (mean ± SD)
of the dogs in each group were as follows: < 10 kg = 6.1 ±
2.2 kg (range 2.2–9.0 kg), 10–30 kg = 21.9 ± 4.7 kg (range
13.7–29.7 kg), and > 30 kg = 38.5 ± 7.8 kg (range 30.3–62.7
kg). Breeds represented in the < 10 kg weight group were
Chihuahua (n = 4), Puggle (3), Dachshund (2), Jack Russell
terrier mix (2), Jack Russell terrier (1), Boston terrier (1),
Chinese crested (1), and Shih tzu (1). Breeds included in
the 10–30 kg weight group were Australian shepherd mix
(2), Border collie mix (2), Boxer mix (2), Pit bull mix (2),
VOL. 00, NO. 0 US EVALUATION OF ADRENAL GLAND SIZE IN DOGS
Blue tick hound (1), Chow chow mix (1), German shepherd
mix (1), Labrador retriever (1), Labrador retriever mix (1),
Rottweiler mix (1), and Plott hound mix (1). Breeds repre-
sented in the > 30 kg weight group included Doberman pin-
scher (2), Labrador retriever (2), Labrador retriever mix (2),
Black and tan hound (1), Boxer (1), German shepherd (1),
Great dane (1), Golden retriever (1), Greyhound mix (1),
Red bone hound (1), Rottweiler mix (1), and Weimaraner
(1). There were seven neutered males and eight spayed fe-
males in the < 10 kg weight group, two intact males, four
neutered males, and nine spayed females in the 10–30 kg
weight group, and 11 neutered males and four spayed fe-
males in the > 30 kg weight group. The mean age was 3
years (range 1–6 years), 3 years (range 1–5 years), and 4
years (range 2–6 years), for the < 10 kg, 10–30 kg, and >
30 kg groups, respectively.
Adrenal glands were visualized in both planes in all dogs
preferentially using a subcostal approach where the adrenal
glands were cranially positioned. However, in some of the
dogs > 30 kg, an intercostal approach was necessary for
visualizing the right adrenal gland as a result of its more
cranial anatomical position compared to the left adrenal
gland.
A significant difference was found between body weight
groups for each adrenal gland measurement regardless of
observer or adrenal gland side (P < 0.0001). There were
no significant differences for either observer when each
observer’s measurements were compared to their own (in-
traobserver difference) for any of the adrenal gland pa-
rameters in each of the body weight groups regardless of
adrenal gland side (P = 0.37 – 0.99).
A significant difference was found between observers (in-
terobserver difference) for all adrenal gland parameters (P
ࣘ 0.0001 – 0.03) except when the thickness of the cranial
pole of the left and right adrenal glands were measured in
the sagittal plane (P = 0.41). Due to the significant differ-
ences noted, the interobserver coefficient of variation was
calculated for each adrenal gland measurement (Table 2);
all were at the upper end or slightly above what is typically
acceptable (14–20%). Table 3 further shows the mean differ-
ence between the two observers’ measurements was small
(0.04–0.28 cm) and the caudal pole thickness of the adrenal
gland measured in a sagittal or a transverse plane had the
least difference between the two observers’ measurements
(0.04–0.07 cm), which was only a 10–13% difference from
the mean of the measurements.
Lastly, no significant difference was detected in any
measurements between the left and right adrenal gland
(P = 0.28–0.53) with two exceptions: (1) the thickness of
the cranial pole of the adrenal gland when measured in the
sagittal plane (P < 0.0001) and (2) the width of the caudal
pole of the adrenal gland when measured in the transverse
plane (P = 0.0008). Both exceptions were noted in the 10–
30 kg and > 30 kg groups. The mean difference for the
5
cranial pole thickness of the left and right adrenal glands
in the sagittal plane in 10–30 kg dogs was 0.05 cm and 0.07
cm, respectively, and for the > 30 kg dogs was 0.06 cm and
0.09 cm, respectively. Similarly, the mean difference for the
caudal pole thickness of the left and right adrenal gland in
the transverse plane in 10–30 kg dogs was 0.10 cm and 0.07
cm, respectively, and for the > 30 kg dogs was 0.05 cm and
0.09 cm, respectively.
The mean, range, and standard deviation for each
adrenal gland measurement in each body weight group are
summarized in Table 4 while 95% confidence intervals (CI)
are provided in Table 5. Each adrenal gland parameter was
statistically different between the three groups (P < 0.001).
The correlations between body weight and the length of the
adrenal glands measured in the sagittal plane for each of
the three groups and between body weight and the cranial
pole thickness of the adrenal glands measured in the sagit-
tal plane for dogs 10–30 kg were significant and moderate
(r = 0.35 – 0.69; P < 0.001). The remainder of the correla-
tions for each adrenal gland parameter were weak (r = 0.09
– 0.28; P > 0.0001 – 0.21). However, all of the weak corre-
lations were significant except for the caudal pole thickness
of the adrenal glands measured in the sagittal plane for
dogs > 30 kg and the caudal pole thickness of the adrenal
glands measured in the transverse plane for dogs < 10 kg
and > 30 kg (Table 6).
Discussion
In this study, we detected a relationship between ultra-
sonographically measured adrenal gland dimensions and
body weight in healthy dogs. Importantly, the currently ac-
cepted cut-off value for thickness of the adrenal gland 0.74
cm,5,6 which has been adopted as a means of distinguish-
ing adrenal gland enlargement in dogs regardless of body
weight, may not be appropriate for small to medium breed
dogs. In this study, dogs in the < 10 kg or 10–30 kg body
weight groups all had measurements (cranial or caudal pole
thickness or caudal pole width) in any plane (sagittal or
transverse) less than 0.64 cm and 0.70 cm, respectively as
shown by the range of measurements obtained (Table 4).
Further, the upper threshold of the 95% confidence inter-
val of the mean for the cranial or caudal pole thickness or
caudal pole width in any plane for dogs in the < 10 kg or
10–30 kg body weight groups was 0.54 cm and 0.64 cm, re-
spectively (Table 5). Thus, more precise cut-off values may
be able to be established for adrenal gland size by catego-
rizing dogs as < 10 kg, 10–30 kg, or > 30 kg in an effort
to supplement a diagnosis of hyperadrenocorticism. Two
earlier studies which evaluated the caudal pole thickness of
the adrenal glands in a sagittal plane in dogs < 10 kg found
the cut-off value for this dimension to be < 0.5911 cm and
0.6017 cm. We wanted to relate these findings in dogs < 10
kg with dogs of other sizes. Therefore, when dividing our
6 SOULSBY ET AL. 2014

TABLE 2. Interobserver Coefficient of Variation of Body Weight Groups and Adrenal Gland Measurements

Body Weight
< 10 kg 10–30 kg > 30 kg
(n = 15) (n = 15) (n = 15)
Variable Coefficient of Variation Coefficient of Variation Coefficient of Variation
Sagittal plane
Length 18% 19% 15%
Cranial pole thickness 17% 16% 20%
Caudal pole thickness 16% 16% 17%
Transverse plane
Caudal pole thickness 18% 14% 14%
Caudal pole width 18% 15% 16%

kg, kilograms; n, number of dogs.

TABLE 3. Mean Difference Between Observers’ Measurements and Percentage Difference from the Mean for Adrenal Gland Measurements in Body
Weight Groups

Body Weight
< 10 kg 10 – 30 kg > 30 kg
(n = 15) (n = 15) (n = 15)
Mean Difference Between Mean Difference Between Mean Difference Between
Variable Observers’ Measurements Observers’ Measurements Observers’ Measurements
Sagittal plane
Length 0.22 cm (14%) 0.27 cm (12%) 0.28 cm (11%)
Cranial pole thickness 0.12 cm (34%) 0.07 cm (16%) 0.08 cm (16%)
Caudal pole thickness 0.04 cm (11%) 0.06 cm (13%) 0.07 cm (13%)
Transverse plane
Caudal pole thickness 0.04 cm (10%) 0.06 cm (12%) 0.07 cm (12%)
Caudal pole width 0.04 cm (11%) 0.06 cm (13%) 0.10 cm (17%)

kg, kilograms; n, number of dogs; cm, centimeters;%, percentage of the mean.

TABLE 4. Comparison of Body Weight Groups and Adrenal Gland Measurements

Body Weight
< 10 kg 10 – 30 kg > 30 kg
(n = 15) (n = 15) (n = 15)
Variable Mean∗ Range SD Mean∗ Range SD Mean∗ Range SD
Weight (kg) 6.13 2.20–9.00 2.07 21.89 13.70–29.70 4.66 38.51 30.30–62.70 7.83
Sagittal plane (cm)
Length 1.61 0.90–2.39 0.29 2.19 1.23–3.24 0.41 2.66 1.62–3.78 0.41
Cranial pole thickness 0.35 0.20–0.56 0.06 0.43 0.28–0.69 0.07 0.50 0.29–0.88 0.10
Caudal pole thickness 0.37 0.24–0.54 0.06 0.45 0.31–0.68 0.07 0.54 0.33–0.80 0.09
Transverse plane (cm)
Caudal pole thickness 0.40 0.27–0.58 0.07 0.50 0.36–0.70 0.07 0.58 0.37–0.81 0.08
Caudal pole width 0.38 0.26–0.64 0.07 0.48 0.31–0.66 0.07 0.58 0.32–0.82 0.09
∗
The mean for all measurements is statistically different between the body weight groups (P < 0.001).
kg, kilograms; n, number of dogs; SD, standard deviation; cm, centimeters.

TABLE 5. Ninety-five Percent Confidence Intervals for Body Weight Groups and Adrenal Gland Measurements

Body Weight
< 10 kg 10 – 30 kg > 30 kg
(n = 15) (n = 15) (n = 15)
Variable Mean∗ 95% Confidence Interval† Mean∗ 95% Confidence Interval† Mean∗ 95% Confidence Interval†
Sagittal plane (cm)
Length 1.61 1.03–2.19 2.19 1.37–3.01 2.66 1.84–3.48
Cranial pole thickness 0.35 0.23–0.47 0.43 0.29–0.57 0.50 0.30–0.70
Caudal pole thickness 0.37 0.25–0.49 0.45 0.31–0.59 0.54 0.36–0.72
Transverse plane (cm)
Caudal pole thickness 0.40 0.26–0.54 0.50 0.36–0.64 0.58 0.42–0.74
Caudal pole width 0.38 0.24–0.52 0.48 0.34–0.62 0.58 0.40–0.76
∗
The mean for all measurements is statistically different between the body weight groups (P < 0.001).
†
Mean ±2 standard deviations.
kg, kilograms; n, number of dogs; cm, centimeters.
VOL. 00, NO. 0 US EVALUATION OF ADRENAL GLAND SIZE IN DOGS
TABLE 6. Correlation of Body Weight Groups and Adrenal Gland Measurements
< 10 kg
(n = 15)
r P- r P-
Variable Value Correlation Value Value
Sagittal plane
Length 0.60 Moderate <0.0001 0.59
Cranial pole thickness 0.24 Weak 0.0010 0.35
Caudal pole thickness 0.24 Weak 0.0011 0.18
Transverse plane
Caudal pole thickness 0.10 Weak 0.2043 0.28
Caudal pole width 0.19 Weak 0.0122 0.24
Scale used to qualify the correlation was r = 0 – 0.3: weak, r = 0.31 – 0.7: moderate, and r ࣙ 0.71: strong.
kg, kilograms; n, number of dogs; cm, centimeters.
population, we kept dogs < 10 kg as representative group
for small breed dogs and arbitrarily divided dogs into two
additional weight categories of 10–30 kg and > 30 kg to rep-
resent groups of medium and large breed dogs, respectively.
In our study, as in earlier studies,5,7,12 the length of the
adrenal glands measured in the sagittal plane had the high-
est correlation, which was moderate, with body weight
(Table 6). The finding of only weak to moderate correla-
tions (r = 0.09 – 0.35) between the remaining adrenal gland
measurements and body weight may have been due to the
small sample size in each body weight group (n = 15). In
addition, the weakest correlations, i.e. caudal pole thick-
ness of the adrenal gland in the sagittal plane for dogs >
30 kg and the caudal pole thickness of the adrenal gland in
the transverse plane for dogs < 10 kg and > 30 kg, were not
statistically significant (P > 0.05). If the sample size were
larger for each of the body weight groups, the correlations
may have been stronger and reached significance for all.
The finding of significant interobserver differences and
a high normal to above normal coefficient of variation for
each adrenal gland measurement (Table 2) was unexpected.
At the time the study was completed, one of the observers
(S.N.S.) was beginning the second year of a radiology resi-
dency. The other observer (J.A.H.) is a board-certified radi-
ologist with over 20 years of experience and whose primary
modality of interest is ultrasound. It is well understood
that the findings of ultrasonography are highly observer-
dependent based on skill level. Ultrasonographic measure-
ments of any organ, but particularly the adrenals, depend
on the expertise of the observer and the measured length
and width of both adrenal glands increases with greater
training of the observer.12 Thus, the significant interob-
server differences in our study could be due to a difference
in experience. However, the mean differences between the
two observers’ measurements were minimal, particularly
for the measurements of the thickness of the caudal pole of
the adrenal glands in both a sagittal and transverse plane
(Table 3). Therefore, the interobserver variability was likely
statistically, but not clinically significant.
7
Body Weight
10 – 30 kg > 30 kg
(n = 15) (n = 15)
r
Correlation Value Value Correlation P- Value
Moderate <0.0001 0.69 Moderate <0.0001
Moderate <0.0001 0.17 Weak 0.0256
Weak 0.0184 -0.09 Weak 0.2082
Weak 0.0001 0.09 Weak 0.2089
Weak 0.0010 0.18 Weak 0.0138
Distance measurement errors in ultrasonography are due
to inherent image pixelation, which are random in nature
and present in all digital images, and modality-specific reg-
istration errors, which result from the image acquisition
process.21 Digital caliper measurements in ultrasound are
dependent on image blurring and the caliper placement skill
of the operator. Vertical digital caliper measurements are
assumed not to have error since these measurements only
have to take into account the axial blurring of the target’s
image, while horizontal digital caliper measurements take
into consideration beam width and result in a wider lat-
eral blurring of the target’s image.21 Therefore, it has been
suggested that with careful technique, horizontal measure-
ments have the likelihood of random ± 1 pixel error in each
cursor’s placement.21 Pixelation errors are small in clinical
images, so for a typical pixel with of 0.30 mm, the maxi-
mum error would be ± 0.64 mm, ± 1.20 mm, and ± 1.80
mm for cursor placement uncertainties of ± 1, ± 2, and ± 3
pixel widths, respectively.21 Ultrasound-specific errors are
due to target misregistration and edge shifting, which are
unavoidable in clinical ultrasound images but adds most of
the unpredictability of error in distance measurements.21
The authors attempted to minimize error and improve ac-
curacy by following published recommendations including
(1) performing many measurements (three in this study for
each adrenal gland measurement by each observer) and av-
eraging their results; (2) using a separate ultrasound image
for each of the parameters measured using digital calipers,
using a standard transducer; (3) selecting a standard fre-
quency range and multizone focus scheme for the trans-
ducer; (4) placing the structure to be measured in the center
of the slice thickness; (5) orienting the measured structure
in the scan plane so the distance to be measured is as close
to possible to being parallel to the image lines; (6) magni-
fying the structure to be imaged so it occupies at least one
half of the image field of view, and (7) adjusting the gain to
obtain a standard gray-scale of the anatomy.21 One study
in humans determined there was an error of less than 20%
for ultrasonographic measurements in 77% of normal and
8 SOULSBY ET AL.
pathologic aortic walls.22 Using the data from the study by
Grooters et al., we calculated a similar error of an average
of 21% where ultrasonographic measurements underesti-
mated gross measurements of the adrenal glands.8
An additional unexpected finding was detection of a sig-
nificant difference between the left and right adrenal glands
for the thickness of the cranial pole measured in the sagit-
tal plane and the width of the caudal pole measured in the
transverse plane. The difference in the thickness of the cra-
nial pole measured in the sagittal plane between the left and
right adrenal glands could be explained by the variation in
the gross structure of the cranial pole of the adrenal glands.
Both observers subjectively reported occasional difficulty
in their ability to completely distinguish the cranial pole
of the adrenal gland regardless of side or body weight of
the dog. The inability to fully evaluate the cranial poles
may be due to the slight dorsoventral flattening of the left
adrenal gland while the cranial pole of the right adrenal
gland has an acute angular bend with the end of the cra-
nial pole projected cranially.23 This angular bend can result
in the cranial pole of the right adrenal gland having an
“arrowhead” shaped appearance2 and make measurement
of this portion of the adrenal gland difficult. The “arrow-
head” shape of the cranial pole was noted by both observers
in some dogs in the current study. In such cases, both ob-
servers attempted to measure the cranial pole of the adrenal
gland toward the tip of the “arrowhead.” The difference in
shape between the cranial poles of the right and left adrenal
glands may also account for the difference in measurements
of the cranial pole of the left and right adrenal glands. Thus,
delineation and measurement of the cranial poles is more
challenging than that of the caudal poles of each adrenal
gland. A similar conclusion about the difficulty in visual-
izing and measuring the cranial pole of the adrenal glands
has been reported.12 In addition, numerous studies have
documented that the right adrenal gland is more difficult
to image as compared to the left adrenal gland.5,7,16,20 The
difference in the width of the caudal pole measured in the
transverse plane can be explained by the lack of skill by
both observers in evaluating the adrenal gland in this man-
ner. The transverse plane is not typically used to image the
adrenal glands as part of the ultrasound examination in our
clinical patients. Also, it has been previously reported that
if the measurement for the width of the adrenal gland in
the transverse plane was taken at an oblique angle by one
or both observers, the width could be overestimated.5–7
Therefore, for several reasons, the best measurement for
assessing adrenal gland size appears to be the thickness
of the caudal pole measured in the sagittal plane. First,
no intraobserver differences were detected for either ob-
server with regard to this dimension regardless of whether
the data were examined separately for each observer or
pooled for both observers. Second, although interobserver
differences were detected when the data were pooled, these
2014
differences were deemed clinically insignificant. This was
decided based on the mean differences for each adrenal
gland measurement between the two observers being
minimal (0.04–0.28 cm) for each of the three body weight
groups as shown in Table 3. The minor disparities noted
in the measurements between the two observers were most
likely a result in the difference in experience level between
the two sonographers performing the measurements. De-
spite the variation in experience level, the mean differences
between the two observers when measuring the caudal pole
of the adrenal gland in a sagittal plane was only 0.04–0.07
cm. Third, a significant difference in the thickness of the
caudal pole between the left and right adrenal gland was
not detected. Fourth, both observers were always able to
easily and reliably visualize the caudal pole of the adrenal
gland in the sagittal plane; the caudal pole is often more
clearly visually defined and consistently has a similar shape
than the cranial pole and the adrenal glands are typically
evaluated in a sagittal plane rather than a transverse plane
ultrasonographically. Similarly, previous studies found that
the thickness of the caudal pole of the adrenal gland mea-
sured in the sagittal plane best correlated with grossly mea-
sured adrenal glands5,6,8 and had the least intraobserver
and interobserver variability.9,12
Dogs have great variability in body weight. Our hypoth-
esis was that adrenal gland measurements varied with body
weight. Our objective was to see if body weight size made a
difference in this pilot study to determine if eventually more
precise reference intervals for adrenal size in three different
weight categories of dogs could be established. Based on
previous research using a single cut-off value of 0.74 cm
for distinguishing a normal adrenal gland from one that
is enlarged for all dogs regardless of their body size does
not appear to be appropriate. Thus, in the populations of
dogs used in this study, the authors of this paper found the
following values for the maximum thickness of the caudal
pole of the adrenal gland in the sagittal plane for either the
left or the right adrenal gland in normal, healthy dogs: (1) ࣘ
0.54 cm for dogs < 10 kg, (2) ࣘ 0.68 cm for dogs 10–30 kg,
and (3) ࣘ 0.80 cm for dogs > 30 kg. However, additional
studies evaluating at risk populations of dogs (e.g., older
dogs) and dogs with known hyperadrenocorticism for fine
tuning of these suggested cut-off values.
There were a few factors which were limitations in this
study. First, the overall sample size was only 45 dogs,
with 15 dogs in each body weight group and creating
authoritative reference intervals require a larger population
of dogs. However, this pilot study showed that even with
only 15 dogs in each body weight group, a significant
difference was seen with regard to the upper limit of
what is considered normal for the caudal pole thickness
of the adrenal gland in a sagittal plane in dogs divided
into different body weights. In addition, we chose our
new cut-off values for the thickness of the caudal pole
VOL. 00, NO. 0 US EVALUATION OF ADRENAL GLAND SIZE IN DOGS
of the adrenal gland measured in a sagittal plane based
on the upper threshold of the recorded range for each
body weight group rather than 95% confidence interval
of the mean ± two standard deviations, because prior
studies3,5,8,11,16,17 have historically used this same method.
The difference in the proposed new cut-off values between
dogs weighing < 10 kg and dogs weighing 10–30 kg was
0.14 cm and the difference in the proposed cut-off values
between dogs weighing 10–30 kg and dogs weighing > 30
kg was similar at 0.12 cm. Additional research is needed
to acquire a larger sample size in each weight group and
determine whether the proposed cut-off values from our
study are accurate. Second, only dogs between 1 and 6
years of age and with a body condition score of 2 to 6 out
of 9 were used. Including dogs of all ages and body weight
condition could have effects on adrenal gland size as well
as the ability to image and measure them accurately.
Specific endocrine testing (e.g., an ACTH stimulation
test, a low-dose dexamethasone suppression test, or a urine
cortisol to creatinine ratio) to definitively rule out under-
lying hyperadrenocorticism was not done. The most re-
cent consensus statement from the American College of
Veterinary Internal Medicine on diagnosing canine hyper-
adrenocorticism states that hyperadrenocorticism is a clin-
ical diagnosis and testing for this disease is not warranted
in dogs without clinical signs of hyperadrenocorticism.1 In
our population of dogs, it was determined that none of the
dogs were likely to have hyperadrenocorticism based on
REFERENCES
1. Behrend EN, Kooistra HS, Nelson R, et al. Diagnosis of spontaneous
canine hyperadrenocorticism: 2012 ACVIM consensus statement (small an-
imal). J Vet Intern Med 2013;27:1292–1304.
2. Graham J. Adrenal glands. In: Pennick D, d’Anjou M-A (eds): Atlas
of small animal ultrasonography. Ames: Blackwell, 2008;385–396.
3. de Chalus T, Combes A, Bedu A-S, et al. Ultrasonographic adrenal
gland measurements in healthy Yorkshire terriers and Labrador retrievers.
Anat Histol Embryol 2013;42:57–64.
4. Widmer WR, Guptill L. Imaging techniques for facilitating diag-
nosis of hyperadrenocorticism in dogs and cats. J Am Vet Med Assoc
1995;206:1857–1864.
5. Barthez PY, Nyland TG, Feldman EC. Ultrasonographic evaluation
of the adrenal glands in dogs. J Am Vet Med Assoc 1995;207:1180–1183.
6. Barthez PY, Nyland TG, Feldman EC. Ultrasonography of the
adrenal glands in the dog, cat, and ferret. Vet Clin North Am Small Anim
Pract 1998;28:869–885.
7. Douglass JP, Berry CR, James S. Ultrasonographic adrenal gland
measurements in dogs without evidence of adrenal disease. Vet Radiol Ul-
trasound 1997;38:124–130.
8. Grooters AM, Biller DS, Merryman J. Ultrasonographic parameters
of normal canine adrenal glands: comparison to necropsy findings. Vet Ra-
diol Ultrasound 1995;36:126–130.
9. Barberet V, Pey P, Duchateau L, et al. Intra- and interobserver vari-
ability of ultrasonographic measurements of the adrenal glands in healthy
beagles. Vet Radiol Ultrasound 2010;51:656–660.
10. Hoerauf A, Reusch C. Ultrasonographic evaluation of the adrenal
glands in healthy dogs, dogs with no evidence of endocrine disease and dogs
with Cushing’s disease. Vet Radiol Ultrasound 1995;36:434 (abstr.).
9
the animals’ normal history, physical examination, blood
work, and urinalysis, and therefore, specific endocrine test-
ing was not performed. For future studies, comparing nor-
mal, healthy dogs to dogs with confirmed hypoadrenocor-
ticism or hyperadrenocorticism and/or dogs with other
medical conditions or dogs on medications such as insulin,
steroids, or antibiotics, would allow sensitivity and speci-
ficity as well as false positive and false negative rates to be
calculated for our proposed new cut-off values.
In conclusion, we found that adrenal gland size varies
significantly between dogs divided into < 10 kg, 10–30 kg,
and > 30 kg groups. We propose that an adrenal gland is
likely to be normal in size if the thickness of the caudal
pole of the adrenal gland in the sagittal plane is (1) ࣘ 0.54
cm for dogs < 10 kg, (2) ࣘ 0.68 cm for dogs 10–30 kg,
and (3) ࣘ 0.80 cm for dogs > 30 kg. These proposed new
cut-off values should be used cautiously until additional
studies involving a larger number of dogs, older dogs (who
are more likely to be at risk for hyperadrenocorticism) and
dogs with known hyperadrenocorticism divided into similar
weight groups can be performed to support or refute our
conclusions.
ACKNOWLEDGMENTS
The authors would like to thank James C. Wright, DVM, PhD,
DACVPM for his help with the statistical analysis and are grateful to
the Department of Clinical Sciences of the Auburn University College
of Veterinary Medicine for financial support of this project.
11. Choi J, Kim H, Yoon J. Ultrasonographic adrenal gland mea-
surements in clinically normal small breed dogs and comparison with
pituitary-dependent hyperadrenocorticism. J Vet Med Sci 2011;73:985–
989.
12. Mogicato G, Layssol-Lamour C, Conchou, F, et al. Ultrasono-
graphic evaluation of the adrenal glands in healthy dogs: repeatability, re-
producibility, observer-dependent variability, and the effect of bodyweight,
age and sex. Vet Rec 2011;168:130–135.
13. Wenger M, Mueller C, Kook PH, Reusch CE. Ultrasonographic
evaluation of adrenal glands in dogs with primary hypoadrenocorticism or
mimicking disease. Vet Rec 2010;167:207–210.
14. Hoerauf A, Reusch C. Ultrasonographic evaluation of the adrenal
glands in six dogs with hypoadrenocorticism. J Am Anim Hosp Assoc
1999;35:214–218.
15. Hoerauf A, Reusch C. Ultrasonographic characteristics of both
adrenal glands in 15 dogs with functional adrenocortical tumors. J Am Anim
Hosp Assoc 1999;35:193–199.
16. Grooters AM, Biller DS, Theisen SK, Miyabayashi T. Ultrasono-
graphic characteristics of the adrenal glands in dogs with pituitary-dependent
hyperadrenocorticism: comparison with normal dogs. J Vet Intern Med
1996;10:110–115.
17. De Marco V, Pereira RS, Kage NK, et al. Ultrasonographic adrenal
glands thickness measurement in dogs with pituitary-dependent hypera-
drenocorticism in comparison with normal dogs matched by weight body. J
Vet Intern Med 2010;24:746–747 (abstr.).
18. Benchekroun G, de Fornel-Thibaud P, Rodriguez Piñeiro MI,
et al. Ultrasonography criteria for differentiating ACTH dependency
from ACTH independency in 47 dogs with hyperadrenocorticism
10 SOULSBY ET AL. 2014

and equivocal adrenal asymmetry. J Vet Intern Med 2010;24:1077–
1085.
19. Bertolini G, Furlanello T, De Lorenzi D, Caldin M. Computed to-
mographic quantification of canine adrenal gland volume and attenuation.
Vet Radiol Ultrasound 2006;5:444–448.
20. Nyland TG, Mattoon JS, Herrgesell EJ, Wisner ER. Adrenal glands.
In: Nyland TG, Mattoon JS (eds): Small animal diagnostic ultrasound, 2nd
ed. Philadelphia: Saunders, 2002;196–206.
21. Goldstein A. Errors in ultrasound digital image distance measure-
ments. Ultrasound Med Biol 2000;26:1125–1132.
22. Pignoli P, Tremoli E, Poli A, et al. Intimal plus medial thickness of
the arterial wall: a direct measurement with ultrasound imaging. Circulation
1986;74:1399–1406.
23. Hullinger RL. The endocrine system. In: Evans HE (ed): Miller’s
anatomy of the dog, 3rd ed. Philadelphia: W.B. Saunders, 1993;559–
585.