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Small Animal Medicine II > Chronic Hepatobiliary Disease > Flashcards

Chronic Hepatobiliary Disease Flashcards

1
Q

What are some chronic hepatobiliary diseases?

A
  • chronic hepatitis
  • copper hepatopathy
  • cirrhosis
  • neoplasia
  • vacuolar hepatopathy
  • nodular hyperplasia
  • cholecystitis
  • GBM
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2
Q

What is chronic idiopathic hepatitis? What are 3 histological signs?

A

insult ot the liver initiates immune response –> Labrador, Doberman, Cocker Spaniel

  1. hepatocellular apoptosis/necrosis
  2. regeneration with fibrosis
  3. mononuclear or mixed inflammatory infiltration
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3
Q

What are 5 possible causes of chronic hepatitis?

A
  1. infectious
  2. drugs/toxins - Phenobarbital in dogs
  3. copper buildup
  4. autoimmune - Dobermans
  5. idiopathic**
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4
Q

What induces immune-mediated chronic hepatitis? What 3 things are seen histologically/biochemically?

A

exposure to certain triggers (pathogen, drug, vaccination, toxin, change in intestinal microbiome) induce T-cell mediated immune response targeting liver-specific epitopes –> cause commonly absent at diagnosis

  1. lymphocytic infiltrates in the liver
  2. abnormal expression of MCH II proteins
  3. positive serum autoantibodies
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5
Q

What signs are associated with chronic idiopathic hepatitis?

A

insidious onset!

  • ascites
  • increased ALT, ALP +/- decreased albumin and/or hyperbilirubinemia
  • can be asymptomatic
  • nonspecific!
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6
Q

What are 5 things seen on AUS in cases of chronic idiopathic hepatitis? What is required for definitive diagnosis?

A
  1. normal, small (cirrhosis), or enlarged liver
  2. nodular appearance with increased or normal echogenicity
  3. portal hypertension
  4. abdominal fluid –> ascites

no sensitive or specific –> U/S can miss mild liver disease and signs seen are not specific to liver disease only –> need biopsy

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7
Q

What is copper hepatopathy? What 3 breeds are predisposed?

A

dysfunction in copper metabolism in the liver causes buildup –> ROS production

  1. Bedlington Terrier
  2. Labrador
  3. Doberman

(middle aged –> takes time for buildup to levels of toxicity

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8
Q

What signs are associated with copper hepatopathy?

A
  • hepatic failure signs
  • cirrhosis with progressive disease
  • increased ALT +/- ALP
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9
Q

What is required for copper hepatopathy diagnosis? How can etiology be determined?

A

liver biopsy and copper quantification

  • PRIMARY = centrilobular
  • SECONDARY = periportal, due to severe cholestasis
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10
Q

What is cirrhosis? What signs are most commonly associated?

A

end-stage inflammatory disease in the liver marked by bridging fibrosis, nodular regeneration, and distortion of hepatic architecture –> irreversible

  • ascites
  • signs of liver failure
  • small, irregular liver
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11
Q

How is cirrhosis diagnosed? Treated?

A

AUS and liver biopsy

treat underlying disease and manage complications, like hepatoencephalopathy, ascites, and portal hypertension

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12
Q

What hepatic neoplasias are most common in dogs and cats?

A

DOGS - metastatic > primary hepatic, malignant > benign

CATS - primary hepatobiliary neoplasia > metastasis

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13
Q

What 3 neoplasias commonly metastasize to the liver?

A
  1. spleen
  2. pancreas
  3. GI
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14
Q

What is the most common malignant liver tumor in dogs? How is it treated? What is prognosis like?

A

hepatocellular carcinoma

surgical resection

good, low rate of recurrence

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15
Q

What benign neoplasias commonly are seen in the liver?

A

hepatocellular adenoma or hepatoma

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16
Q

What causes steroid hepatopathy? In what animals is this most commonly seen?

A

exogenous/endogenous corticosteroids cause ALP isoenzyme induction leading to accumulation of glycogen in hepatocytes –> vacuolar hepatopathy (benign, reversible!)

DOGS with hyperadrenocorticism, DM, hepatic lipidosis, lipemia, or hypertriglyceridemia or are being treated with Prednisone - not seen in cats because the lack the cALP isoenzyme

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17
Q

What are the most common signs of steroid hepatopathy? What is seen on AUS? Bloodwork?

A
  • PU/PD
  • hepatomegaly
  • pot belly
  • panting
  • thin skin

hepatomegaly, hyperechoic due to swelling

moderate to severe elevations in ALP +/- ALT

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18
Q

What is nodular hepatic hyperplasia? What is seen on bloodwork? How is it diagnosed?

A

benign, asymptomatic, old-age related change to the liver seen in 15-60% of dogs that may look like neoplasia on diagnostic imaging - no tx necessary!

mild to marked increased ALP

histopath

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19
Q

What is required to diagnose most liver diseases? What does it provide?

A

liver biopsy

  • definitive diagnosis
  • prognosis
  • treatment
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20
Q

What are 3 indications for liver biopsies?

A
  1. persistently increased liver enzyme activities without an underlying cause
  2. hepatic mass
  3. hepatomegaly of unknown cause
21
Q

What preparation should be done before liver biopsies?

A

assess BMBT, platelets, and clotting times

  • especially in Dobermans!
22
Q

Liver biopsy techniques:

A

unable to assess hemorrhage with percutaneous needle biopsies - especially important to assess platelets in these patients before and PCV/TS after

23
Q

What is the least invasive option for liver biopsies? What are 3 cons to this technique?

A

percutaneous U/S guided with heavy sedation or anesthesia–> Tru-Cut

  1. cannot visualize liver lobes
  2. post-biopsy hemorrhage is common and can’t be visualized
  3. unable to biopsy multiple lobes
24
Q

What are 4 pros to laparoscopic liver biopsies? What is required for this technique?

A
  1. minimally invasive
  2. can visualize liver and hemorrhage (can also stop with pressure and trufoam)
  3. bigger samples compared to Tru-Cut
  4. multiple lobes can be biopsied

anesthesia

25
Q

What is the most invasive method of obtaining a liver biopsy? What are 4 pros?

A

surgical biopsy (anesthesia!!)

  1. can visualize liver
  2. provides largest samples
  3. can sample multiple lobes
  4. can visualize and stop hemorrhage

(especially good for cats where multiple disease processes are occurring - triaditis!)

26
Q

What 3 tests that should be performed on liver biopsies?

A
  1. histopathology
  2. copper analysis (dogs)
  3. culture - aerobic, anaerobic, best yield with cholecystocentesis for bile culture

if results don’t correlate with histopath findings, request special stains or ask for opinions from the pathologist

27
Q

Hepatic diseases:

A
28
Q

What treatment plan is recommended for chronic idiopathic hepatitis?

A

empirical treatment

  • inflammation
  • arrest fibrosis
  • anti-oxidation
  • address complications
29
Q

What are the 4 major empirical treatments recommended for chronic idiopathic hepatitis?

A
  1. Prednisone - control inflammation, antifibrotic
  2. Ursodiol - cholerectic, reduce toxic bile acids, immunomodulatory
  3. SAMe, Vitamin C - antioxidants
  4. highly digestible, high quality protein diet - hepatic regeneration
30
Q

What are 3 other options for immunosuppressive therapy for immune hepatitis?

A
  1. Azathioprine - hepatotoxicity common!
  2. Cyclosporine
  3. Mycophenolate
31
Q

What are the 3 most important treatments for hepatic fibrosis? What else can be added?

A
  1. Prednisone
  2. Ursodiol
  3. SAMe

colchicine, zinc salts, D-Pencillamine

32
Q

Copper-associated hepatopathy treatments:

A
33
Q

What levels are indicative of copper hepatopathy?

A

> 1500-200 ppm

34
Q

What 3 functions does D-penicillamine have to treat copper hepatopathy? How is it given?

A
  1. binds hepatic Cu and is eliminated in the urine
  2. increases metallothionein in hepatocytes and enterocytes to detoxify intracellular Cu and facilitate fecal elimination
  3. mild anti-inflammatory and anti-fibrotic

given PO on an empty stomach (food decreases bioavailability) in combination with dietary Cu restriction for 6-9 months

35
Q

How is treatment efficacy of copper hepatopathy determined? What lifelong therapy is recommended?

A

repeat biopsy with Cu quantification or normalization of ALT (continue treatment for 1 month after normal results!)

dietary Cu restriction +/- low dose zinc or D-penicillamine 2-3x weekly

36
Q

What 2 functions does zinc acetate have for the treatment of copper hepatopathy?

A
  1. interferes with enteric Cu uptake via metallothionein induction
  2. decreases hepatic Cu concentration slowly (not appropriate for acute treatment!)

combine with Cu-restricted diet!

37
Q

What diet is recommended for cases of copper hepatopathy?

A

low copper, high zinc diet with D-penicillamine for Cu chelation

  • MUST have sufficient protein
38
Q

What are 2 poor prognostic indicators with copper hepatopathy?

A
  1. ascites
  2. bridging portal fibrosis –> cirrhosis
39
Q

What change in bloodwork is expected in patients with liver disease being treated with Prednisone?

A

increased ALP –> look at original pattern, ALT should still improve

40
Q

What 4 bloodwork changes are expected in cases of bacterial cholangiohepatitis? What signs are associated?

A
  1. inflammatory leukogram - chronic neutrophilia
  2. increased liver enzymes - ALP>ALT
  3. hyperbilirubinemia
  4. hypercholesterolemia

vomiting, anorexia, lethargy, jaundice, abdominal pain

41
Q

What 6 bacterial isolates are associated with cholecystitis?

A
  1. E. coli
  2. Enterococcus
  3. Strep
  4. Klebsiella
  5. Clostridium
  6. Bacteroides
42
Q

What presentation is associated with cholecystitis? What changes in bloodwork are seen?

A

ACUTE - sudden onset of abdominal pain, fever, vomiting, lethargy, icterus +/- shock

cholestatic (ALP) to mixed hepatopathy + hyperbilirubinemia

43
Q

What is seen on U/S in cases of cholecystitis? What else is recommended for diagnosis?

A

thickened or irregular GB wall with echogenic GB contents

cholecystocentesis

44
Q

What 4 treatments are recommended for cholecystitis?

A
  1. antibiotics based on C&S
  2. Ursodiol
  3. supportive care
  4. surgery
45
Q

What is the most significant biliary disease in dogs? In what dogs is this most common?

A

GBM

older (10 y/o) Shetland Sheepdogs, Miniature Schnauzers, and Cocker Spaniels

46
Q

What are gallbladder mucoceles? What causes their formation? What systemic diseases are associated?

A

accumulation of mucus within the gallbladded formed when epithelial cells secrete too much mucus in response to injury or with dysmotility of the bile out of the GB

  • hypothyroidism
  • Cushing’s
  • DM
  • hyperlipidemia
47
Q

What complications are associated with gallbladder mucoceles? What signs are associated? What bloodwork changes are seen?

A

GB necrosis and rupture + infection

vomiting, abdominal pain, fever

cholestatic (ALP) to mixed hepatopathy +/- icterus due to obstruction or severe stasis

48
Q

What is characteristic of gallbladder mucoceles on ultrasound?

A

stellate or striated GB contents that do not move and are surrounded by a hypoechoic ring + hyperechoic fluid around the GB indicating rupture

  • kiwi pattern!
49
Q

What medical and surgical treatments are recommended for gallbladder mucoceles/

A

MEDICAL - ursodiol, low-fat diet, antibiotics with concurrent infection

SX - cholecystectomy (to avoid rupture, necrosis, and infection)

Small Animal Medicine II (57 decks)

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