Clinical Hepatic Disease Flashcards by jared Jensen

What are some good questions to ask when a dog presents with vomiting and soft stool

-What does the vomitus look like?
-When exactly is it happening and how many times?
-Does the stool have mucus or blood in it?
-What is the color of blood?
-Has this happened before?
-Any new treats?
-Recent stress?
-Does she tend to get into things?

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Primary gastrointestinal diseases that cause vomiting and soft stool in a dog

Obstructed foreign body
FB causing GI irritation
GI parasitism
GI infectious (Giardia, Isospora)
GI neoplasia
GI toxin
Acute or chronic enteropathy

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Secondary gastrointestinal diseases that cause vomiting and soft stool in a dog

Pancreatitis
Renal disease
Hepatobiliary disease
Addison’s
Systemic inflammation
Systemic infection
Extra-GI neoplasia

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What disorders / diseases involve the biliary tract in the dog

1) Gall bladder mucocele
2) Cholecystitis
3) Cholangitis
4) Cholelithiasis
5) Intrahepatic and extrahepatic cholestasis
6) Congenital structural abnormalities
7) Neoplasia

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What causes neutrophilic cholangitis in the dog

E. coli and Enterococcus spp. most commonly isolated

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What is the most common form of cholangitis in the dog

neutrophilic

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How might dogs with cholangitis present

fever
abdominal pain
icterus
lethargy
dull mentation

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Hyperbilirubinemia in combination with an inflammatory leukogram, fever, or abdominal pain increases the clinical suspicion for

biliary tract disease

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What are causes of destructive cholangitis in the dog

1) Ductopenia
2) Cholestasis, inflammatory infiltrate
3) Portal cirrhosis
4) Drug-related (Clavamox, milbemycin oxime, amitraz, sulfas)

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Cholangitis typically affected what kinds of dogs

Middle aged, middle sized dogs

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Nearly half of cholangitis cases in the dog were positive via bacterial culture for

E. coli and Enterococcus

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What is very common to concurrently occur with cholangitis

gall bladder disease
1) cholecystitis
2) gall bladder mucocele

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Cholecystectomized dogs have an increases risk of

death

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Cholangiohepatitis is when the infection spreads

beyond the portal tracts

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accumulation of thick mucus and/or inspissated bile causing mucinous hyperplasia of the gall bladder

gall bladder mucocele

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Gall bladder mucoceles occur in typically what type of dogs

older small breed dogs
-Shetland Sheepdog
-Border terriers
-American cockerspaniel
-Poms
-Chihuaha
-Miniature Schnauzer

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What are risk factors for gall bladder mucoceles? in the dog

1) Hyperlipidemia
2) Hypothyroidism (weak association)
3) Hyperadrenocorticism
4) Breed of Shetland Sheepdog
5) Concurrent biliary tract disease (inflammation)

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What are the clinical signs of gall bladder mucoceles in the dog

-Vomiting (Bile acid diarrhea)
-Lethargy
-Diarrhea
-Inappetance, hyporexia
-Icterus
-Abdominal pain
-Incidental finding

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What are the blood work changes seen with gall bladder mucoceles in the dog

1) CBC normal or leukocytosis
2) Increased ALP
3) Increased ALT
4) Increased AST
5) Increased GGT
6) Increased cholesterol
7) Increased total bilirubin

Can be relatively unremarkable or only very mild changes

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What kind of cholestasis does leptospirosis cause

Intrahepatic cholestasis and some serovars can only target the liver initially

will cause cholestasis and subsequent hepatocellular damage

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What kind of cholestasis does pancreatitis cause

pancreatitis results in extra-hepatic biliary tract obstruction (EHBTO) which can cause cholestatic and hepatocellular changes

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What are the results of autoimmune hepatitis

predominant hepatocellular changes but can cause a mixed if going on chronically

How do patients with autoimmune hepatitis typically present

thin, losing weight when diagnosed with a mixed hepatopathy

T/F: Cholelithiasis is rare in the dog

True

hepatic ducts converge to cystic duct to become the

common bile duct (CBD)

the common bile duct enters the duodenum alongsidethe

pancreatic duct major duodenal papilla

What is the treatment of choice for gall bladder mucoceles

surgery is considered the treatment of choice in clinically ill patients or dogs with blood work derangements In stable patients with normal blood work, medical management can be pursued for 4-5 months but if not responding then surgery is recommended

What are the consequences of gall bladder mucoceles

-Gall bladder distension -Biliary tract distension -Cholestasis -Gall bladder rupture -Bile peritonits

What does ursodiol do

changes the bile acid composition (more liquid) helps with bile flow

How can you medically manage gall bladder mucoceles

Treat predisposing factors Ursodiol Sam-E, hepatoprotectants Low fat diet

What are the enzymes that when elevated indicate hepatocellular damage

ALT AST SDH

What are the enzymes that when elevated indicate induced cholestasis

ALP GGT

Why might a cat have chronic vomiting and anorexia

Primary: Chronic enteropathy, gastrointestinal neoplasia (non-lymphoma type) Secondary: Renal disease, hepatobiliary disease, idiopathic hypercalcemia, chronic pancreatitis, hyperthyroidism (later stage if really high), extra-GI neoplasia

T/F: cats commonly get gall bladder mucoceles

false- stones and mucoceles are rare in cats

A cat that has chronic vomiting of undigested food and anorexia with icterus and fever. what are primary differentals

Hepatobiliary disease: Cholangitis/ Cholangiohepatitis Neoplasia FIP (dry form)?

Why might cholesterol be increased if an animal is not eating

cholestasis

In cats, cholangitis is divided into 4 groups called

1) Neutrophilic / suppurative cholangitis 2) Lymphocytic, lymphoplasmacytic cholangitis 3) Destructive cholangitis (not yet described in the cat) 4) Chronic cholangitis associated with liver fluke infestation 1+2 are the most common

In the cat, how do you tell neutrophilic / suppurative cholangitis from lymphocytic, lymphoplasmacytic cholangitis

technically based on histopathology neutrophilic cholangitis is predominantly neutrophilic infilatration and depending on how long-standing it may be neutrophilic alone or lymphocytes and plasma cells may start to be present as well but neutrophilic is main cell present

cholangitis becoe cholangiohepatitis if the inflammation breaches the

limiting plate and extends into the parenchyma (beyond portal tracts)

What typically causes feline neutrophilic cholangitis

Bacterial ascending infections (E. coli, Enterococcus spp, polymicrobial) may be associated with cholecystitis, cholecystocholethiasis, ductal plate malformation, etc

in cats, this disease is characterized by ductular proliferation, damage to the biliary epithelium by cell infiltrate, neutrophils in the biliary lumen

feline neutrophilic cholangitis

feline neutrophilic cholangitis signs

50-50 chance febrile may or may not have inflammatory leukogram commonly are hyperbilirubinemic but not always icteric

feline lymphocytic cholangitis require _______ to diagnose

histopathology to diagnose

feline lymphocytic cholangitis

can be predominately lymphocytic or lymphoplasmacytic, also known as non-suppurative requires histopathology to diagnose considered slowly progressive disease infiltration is restricted to portal regions and will have portal fibrosis and biliary ductular proliferation in addition to ductopenia

feline lymphocytic cholangitis is _____________ while feline neutrophilic cholangitis is ______

lymphocytic: slowly progressive neutrophilic: days to weeks, more acute can go septic

Why might feline lymphocytic cholangitis require IHC or PARR to discern from hepatic small cell lymphoma

because it looks like lymphoma with all the lymphocytes 1) PARR on feline hepatic tissue 2) Possible concurrent GI lymphoma, lymphocytes draining GI tract and are in liver 3) Be careful where you submit PARR

How do you treat feline lymphocytic cholangitis

glucocorticoids or chlorambucil -optimal treatments and long-term outcomes are poorly described

What will you see on ultrasound in a cat with feline lymphocytic cholangitis

Bile duct distension, hepatomegaly with mixed echogenicity US may reveal gall bladder sludge thickening or normal

What will you see on ultrasound in a cat with feline neutrophilic cholangitis

Extrahepatic biliary obstruction, lipidosis thickened GB wall

What empircal therapy might you try for a cat with feline cholangitis

Pradoflaxacin or Clavamox trial

What can help diagnose feline neutrohpiliccholangitis

ultrasound and cholecystocentesis for cytology and culture

in most suspected neutrophilic bacterial cholangiohepatitis cats, liver values should dramatically improve within

3-4 weeks

if you have an older cat >9 to 10 years that is quite icteric and feels relatively fine aside from some vomiting and weight loss and has not responded to several weeks of antimicrobial therapy then you should suspect

lymphoplasmacytic cholangitis

if you have a more clinically affected younger cat +/- fever and acute signs with mild or no icterus noted then you should suspect

neutrophilic cholangitis