Did you know that SonoPath has a branch in Michigan at the tip of the Mitt? Our branch is called Torch River Veterinary Mobile Services (TRVMS) ; this case of the month highlights our (TRVMS) SDEP® Certified clinical sonographer Dr. Adrianne Waffle, DVM, and her adeptness at securing detailed and accurate ultrasound images for veterinary diagnostics. The case was interpreted by SonoPath CEO/Founder Dr. Eric Lindquist (DMV, DABVP, Cert IVUSS )
We are thankful and proud to say that we partnered with Bay Area Pet Hospital and Dr. Lapa to come to a diagnosis in this case. Read more to find out about Friday night kitty plumbing problems in Torch River, Michigan!
History/clinical signs:
The patient presented to the emergency clinic with a 3-week history of inappetence. He was tentatively diagnosed with hepatic lipidosis by the RDVM when elevated liver values were noted. The owners originally tried outpatient care with mirtazapine and SQ fluids, but the patient’s liver values remained elevated; therefore, they elected inpatient hospitalization.
PE:
The patient was severely jaundiced on presentation. No murmurs were noted. CRT was <2 seconds. Lung fields were clear. Normal mentation and normal hydration based on skin turgor were present. Lymph nodes palpated WNL. Icterus of sclera, oral mucous membranes, and skin noted.
Diagnostics:
Bloodwork:
Treatment:
- Vit K therapy – 0.51 mg/kg Q 12 hrs
- Metoclopramide – 0.2 mg/kg Q 8 hrs
- Ondansetron – 0.1 mg/kg Q 6 hrs
- IV fluid therapy – plasmalyte at 18ml/hr with 30 mEq/L KCl
- Nasogastric tube for feeding
Ultrasonographic Abdominal Findings:
Liver: The liver revealed coarse architecture (consistent with chronic cholangitis), increased portal markings, and “too many tubes” signs/dilated cystic duct/common bile duct. Lobar biliary duct dilation was also noted. The cystic duct was tortuous and dilated as was the common bile duct (up to 8.0 mm). Following the common bile duct distally to the duodenal papilla, the last 1.0 cm of the common bile duct appeared normal; however, just prior to this point, at the junction of the common bile duct with the pancreatic duct, a 1.3cm x 0.77cm isoechoic tissue density was noted, appearing to be the underlying cause of post-hepatic obstruction.
Pancreas: No overt evidence of active inflammatory or neoplastic disease was noted
- Chronic cholangitis/cholangiohepatitis liver pattern
- Post-hepatic obstruction with tissue density at the distal common bile duct – inflammatory polyp versus carcinoma
- Age-related renal changes with slight mineralization and a cyst
INTERPRETATION OF THE FINDINGS & FURTHER RECOMMENDATIONS :
Surgical exploratory with expectation toward liver biopsy, inspection, and bile duct deviation procedure would be necessary. Isoechoic metastatic lesions within the liver cannot be ruled out, as the liver architecture was coarse. If bile duct carcinoma is confirmed in the duodenal papilla, then liver inspection and biopsy are essential. Prognosis is very guarded. CBC pathology review is warranted given the anemia. No evidence of hemorrhage.
Case Outcome:
The patient began eating ravenously and was later discharged. No further update was available.
Causes of icterus are divided into one of three categories. The first is pre-hepatic and is due to the breakdown of RBCs (parasitism, IMHA, drug induced). The liver simply becomes overwhelmed by the amount of bilirubin released from red blood cell breakdown. The second category is hepatic (hepatic lipidosis, infectious disease, neoplasia, etc). The final cause of icterus is post-hepatic, evident in this patient. In the feline, post-hepatic obstruction is most often caused by pancreatitis, neoplasia, stone formation, bile sludge, or parasitism. In this case a soft tissue mass was noted near the termination of the CBD, presumably causing the obstructive pattern noted. If the obstruction could not be resolved with medical management, then surgical biliary diversion would be indicated. However, prognosis is guarded in feline patients, regardless of underlying cause. Mortality may be high early on and those that survive the early post-operative period may develop chronic vomiting and anorexia. As such, surgical intervention is withheld unless no other option exists.
Ultrasound Tips:
- The gallbladder is located on the right side of the liver situated between the right medial and quadrate liver lobes.
- In rare cases, centesis of the gallbladder may cause severe vagal response and asystole in feline patients.
- The gallbladder is viewed in the SDEP® protocol best from the right side in position 11, but can also be seen in positions 9 & 10. In addition, it is viewed from position 11 as the probe is angled to the right shoulder. Less than 10% of cats will have a normal variant in which they have a bilobed or duplex gallbladder.
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