Diseases of the Liver Flashcards
1
Q
What are the 2 intracellular markers?
A
ALT
AST
2
Q
Of ALT and AST, and increase in which is more indicative of severe hepatocellular damage?
A
AST
3
Q
Where is ALT stored?
A
In the cytosol of liver cells
4
Q
Where is AST stored?
A
In the mitochondria and cytosol of cells
5
Q
Which is more liver specific, AST or ALT?
A
ALT
AST is also in skeletal and cardiac muscle
6
Q
T/F: Severity of elevation of AST correlates to degree of liver damage, and is an indicator of prognosis.
A
False.
Severity of elevation of AST correlates to degree of liver damage, but is NOT always an indicator of prognosis.
7
Q
What is important to remember with regards to the half-lives of AST and ALT?
A
They’re short, so if concentration has dropped 50% in 2.5 days, inciting cause is gone
8
Q
If AST>ALT, what else should you check and why?
A
Check CK because AST is also in skeletal muscle, will help you figure out what’s going on.
9
Q
What are the 2 membrane-bound markers?
A
ALKP
GGT
10
Q
Where are ALKP and GGT bound?
A
canicular membrane of gall bladder
11
Q
What is the other difference between ALT&AST and ALKP&GGT?
A
Half-lives
ALKP and GGT have longer half-lives
12
Q
What will induce an increase in ALKP and GGT?
A
Choleostasis
13
Q
In the dog, which is less specific, ALKP or GGT?
A
ALKP is less specific in the dog
14
Q
Where do we see ALKP isoenzymes (5 places)
A
Intesines Kidneys Placenta Bones (yonung, old and neoplasia) Drugs (corticosteroids and phenobarbitone)
15
Q
What 2 drugs act as ALKP isoenzymes?
A
Corticosteroids
Phenobarbitone
16
Q
Why is increased ALKP in a cat so significant?
A
Because they don’t have corticosteroid-associated ALKP so ALKP is VERY liver specific
17
Q
Where does bilirubin come from?
A
RBCs
18
Q
Where is bilirubin stored?
A
Gall bladder
19
Q
How is bilirubin normally eliminated?
A
Conjugated and excreted via bile ducts to get broken down in GI to urobilinogen.
20
Q
What are the 3 general disorders of bilirubin?
A
Pre-hepatic jaundice
Hepatic jaundice
Post-hepatic jaundice
21
Q
What is an example of pre-hepatic jaundice?
A
Hemolysis (IMHA)
22
Q
What is an example of post-hepatic jaundice?
A
Bile duct obstruction
23
Q
What can tell you if you have pre-hepatic jaundice?
A
PCV
24
Q
What is a good way to tell if post-hepatic jaundice?
A
US
If you don’t have signs associated with EHBA, can conclude liver dysfxn.
25
How can you tell if you have hepatic jaundice?
Rule out Pre- and Post-hepatic, consider a biopsy
26
When do you start seeing signs of compromised liver function?
70% destruction
27
What is the best test for liver function?
Ammonia Tolerance Testing
28
What is the second best test for liver function?
Serum Bile Acids
29
How do you perform a serum bile acid test?
12hr fast, take blood sample, challenge with protein (usually tbsp of A/D is good enough), second blood sample take n2hrs post-prandially.
30
In the serum bile acids test, which sample is the most sensitive and specific test?
Post-prandial sample
31
T/F: Post-prandial bile acids is equivalent in sensitivity and specificity to ammonia tolerance test in detecting PSS.
True
32
T/F: Post-prandial bile acids is equivalent in sensitivity and specificity to ammonia tolerance test in detecting parenchymal liver dz.
False
33
When do you start to see hypoalbuminemia?
With less than 33% liver fxn
34
If albumin is significantly low, what will that lead to?
Development of ascites
35
What 2 things does ascites do to us?
Makes biopsy more tricky
| Is a negative prognostic indicator
36
What should we remember about dogs with hypoglycemia?
It's uncommon
37
If we have a dog with hypoglycemia, what should be on our ddx?
Hepatic encephalopathy
38
If we have a dog with hypoglycemia, what 2 tests should be on our list to perform?
BG
| Basal ammonia
39
T/F: Hyperglycemia is more common in cats with liver dz.
True
40
If you have a hyperglycemic cat, what do you want to try to do right away and why?
Regulate glucose
Impact on outcome
Effect on brain fxn and myocardial health
41
What 3 additional tests would you run if you suspect liver dz?
Hematology
Urinalysis
Coagulation panel
42
What would you expect to find on hematology in a liver dz patient?
Non-specific changes
| Mild non-regenerative anemia and thrombocytopenia
43
What is microcytic, hypochromic anemia indicative of (especially in yorkies and danes)?
Abnormal iron metabolism secondary to PSS
44
What would be important to note on a UA of a cat with suspected liver dz?
Increased bilirubin
NOTE: Cats normally have a high threshold for bilirubin so if you're seeing it in the urine, is significant.
NOTE: Small amount in dogs can be normal
45
What are urate crystals on UA of a yorkie pretty diagnostic for?
PSS
46
How much coagulation factor depletion do you need to see prolonged clotting times?
70%
Note very sensitive
47
Which coagulation factor does the liver NOT produce?
Factor VIII
48
What is abdominal radiology good for with liver dz?
Assessing liver size
49
What is abdominal US good for investigating?
Hepatobiliary dz
50
Can a normal US scan exclude hepatic disease?
No, poor correlation between US and surgical/histo findings
51
When would you consider a liver biopsy?
Primary dz of unknown origin in a STABLE animal
52
According to WSAVA, you should not treat with steroids until..?
We have biopsy proven signs of chronicity (fibrosus and mononuclear infiltrate)
53
When is a liver biopsy contraindicated?
If coagulopathy is present
54
If clotting times are prolonged, what should you consider before doing a liver biopsy?
Treat with plasma or Vit K
NOTE: Some people will still give Vit K even if clotting times are normal
55
What parameter should you check before performing a FNA on the liver?
Platelet numbers
56
How is a liver FNA performed?
23G needle with US guidance
57
What should you do while obtaining a liver FNA?
Aspirate multiple areas
58
What is the most sensitive sample for diagnosing cholangeohepatitis?
Bile
59
What parameter should you consider before performing a liver biopsy?
Coagulation factors
60
What is the name of the trigger biopsy needle?
Tru-cut
61
T/F: Tru-cut is the gold standard.
False
62
What is a step you should do before you send your tru-cut biopsy away for histo?
Do an impression for cytology
63
What liver biopsy needle is used for the largest amount of tissue?
Menghini
64
What is the Menghini typically used for?
Investigating copper associated liver dz
65
What is a MAJOR thing to remember with regards to trigger biopsy needles in cats?
Associated with vagal shock and sudden death
66
What is the gold standard for liver histopathology?
Wedge sample via laparoscopy or celiotomy
67
Why is it so good to gain a liver sample via laparoscopy or celiotomy (2 reasons)?
Can visualize and control bleeding
| Can get larger sample
68
What is another thing you can gain from a larger liver sample?
Quantitative copper concentrations
69
What is H&E stain for?
Routine histology
70
What is Masson's trichome stain for?
Cirrhosis and fibrosis (chronic liver pathology)
71
What is PAS stain for?
Vacuolar hepatopathy
72
What is Rubeanic acid/Rhodanine stain for?
Copper
73
What is Congo Red stain for?
Amyloid
74
What is Perl's stain for?
Iron
75
What is a trasnudate?
Low protein (
76
What is a modified transudate?
```
Low protein (2.5-7.5 g/dL)
Low cellularity (1000-1500 cells/mL)
```
77
What is a non-septic exudate?
```
High protein (>3 g/dL)
High cellularity (>5000 cells/mL, neuts with NO bacteria)
```
78
What is a septic exudate?
```
High protein (>3 g/dL)
High cellularity (>5000 cells/mL, neuts with intracellular bacteria)
```
79
What are 2 causes of a transudate?
Hypoalbuminemia (PLE, PLN, Liver failure)
| Portal hypertension
80
What are 3 causes of a modified transudate?
R-sided CHF
Neoplasia
Liver dz
81
What is a cause of an exudate?
FIP
82
What is a cause of a septic exudate?
GI perforation
83
How do you define acute liver disease?
Less than 2 weeks duration
84
What are 5 different causes of acute liver dz?
```
Toxic
Hypoxic
Traumatic
Metabolic
Infectious
```
85
What are the 3 subdivisions of acute liver dz?
Single cell necrosis
Acute hepatic failure
Fulminant hepatic failure
86
What is single cell necrosis?
Isolated cells damaged
87
What might we detect with single cell necrosis?
Usually subclinical/clinically silent.
| Enzyme increases present on routine analysis
88
What is acute hepatic failure?
Widespread necrosis
89
What might we see with acute hepatic failure?
Mental dullness, vomition, PU/PD, icterus
ALT up, ALKP possibly up
Fxn may be maintained
NOTE: Could also be subclinical
90
What is fulminant hepatic failure?
Massive necrosis resulting in coagulopathies and hepatic encephalopathies
91
What do we see in fulminant hepatic failure?
Anorexia, V&D
| ALT markedly increased, ALKP increase follows
92
What is there an increased risk of with fulminant hepatic failure?
Increased risk of the dog dying before discharge
93
What must you address in fulminant helpatic failure?
Colloid and oncotic pressure because these dogs become hypoalbuminemic and suffer from hypoglycemia.
94
How do we diagnose acute liver dz?
Need history to see what/if dog was exposed to
Biochem (looking for elevated enzymes)
Coagulopathies?
US -> diffuse hypoechogenicity? hepatomegaly?
95
What is the standard treatment for acute liver disease?
```
Decontamination
Fluids
Antiemetics (REALLY nauseous, want centrally acting)
PPIs
N-acetyl cysteine or SAMe
Silymarin
```
96
What doe N-acetyl cystein and SAMe do to help the liver?
Both are glutathione donors, so they protect the liver from oxidative damage
97
Why is LRS not good to use in liver failure patients?
Converted in the liver so it can manifest a hyperlactatemia
98
What fluids should you use instead of LRS in a liver failure patient?
Saline solution
99
Although saline would be better than LRS in liver failure dogs, why would you choose LRS instead in a dog with hepatic encephalopathy?
Because saline will acidify the patient, with allows ammonium to pass the BBB more easily which is what we do NOT want
100
Nutritionally, how do we treat acute liver dz?
Provide a good quality, normal protein content
NOTE: Be aware of aromatic amino acids which come from animal proteins. Plant proteins are better
101
What happens if we protein restrict a patient with acute liver dz?
Their BMR will be increased, so if they don't get enough protein in their diet, they will breakdown muscle which also exacerbates hepatic encephalopathy
102
What is the only time you should restrict protein?
If visible clinical hepatic encephalopathy is present
103
What are 4 etiologies for acute liver dz?
Toxins
Metabolic
Infectious
Hypoxia
104
What are 4 toxins that can cause acute liver dz?
Acetaminophen
Carprofen
Diazepam
Aflatoxin
105
What do we see in cats with acetaminophen toxicosis?
Heinz bodies
Hemolytic anemia
Methemoglobinemia
106
What is important to remember about cats with acetaminophen toxicosis?
Cats will die before they develop acute hepatic necrosis
107
What do we see in dogs with acetaminophen toxicosis?
Acute hepatic failure
NOTE: Dogs have a higher tolerance, takes 150-200mg to get to toxic levels
108
Why is a side effect of the "-conazoles" liver failure?
Because it is a P450 enzyme inhibitor
109
What do you do to treat acetaminophen toxicosis?
```
N-acetylcystein
SAMe
Ascorbic acid (Vit. C)
Cimetidine
Support (O2, gastric lavage, emetics, charcoal)
```
110
What 2 things does carprofen cause in labradors?
Idiosyncratic fulminant hepatic injury
| Acute renal injury
111
What should you do if you deicde to put a lab on carprofen?
Warn the owner of the risks and monitor liver enzymes
112
What formulation of diazepam do cats have trouble with?
Oral diazepam
113
What do we see in cats who have been given oral diazepam?
Centrilobular necrosis, myocyte and muscle necrosis
| Hypoglycemia, coagulopathies, icterus and ARF
114
How do you treat a cat who has ingested diazepam?
Support
Vit. K
Blood
N-acetyl cystine
115
What is the most common cause of aflatoxicosis?
Spoiled and contaminated food, usually pre-procesing, the corn is spoiled.
116
What signs do we see of aflatoxicosis?
Groups of dogs affected, high mortality rate
| Bleeding and hypoalbuminemia
117
How do we treat dogs with aflatoxicosis?
Need blood transfusions, FFP and support
118
What is the prognosis for dogs with aflatoxicosis?
Poor
119
What does xylitol do?
Stimulates insulin release and hypoglycemia -> marekdly elevates liver enxymes -> necrosis
120
What do we see with xylitol toxicosis?
Icterus
| Bleeding
121
How do we treat dogs with xylitol toxicosis?
Admit them and start SAMe
122
What are 3 plants that cause acute liver dz?
Cycads
Mushrooms
Chinberry
NOTE: Most of the time, cause will not be apparent
123
How do we treat dogs that have a plant toxicosis causing acute liver dz?
Emesis
Charcoal
Proactively prevent further liver damage
124
How long do we expect to keep a dog with plant toxicosis in the ICU?
About 3 days
125
After discharge, how often do we want to see plant toxicosis dog in again and what are we monitoring?
Want to see them every ~2.5 days to monitor liver enzymes and make sure they've dropped by at least 50% if they haven't returned to normal already.
126
What is the most important liver dz in cats?
Hepatic lipidosis
127
How does hepatic lipidosis occur?
Imbalance in lipid metabolism causes lipid accumulation in the hepatocytes and subsequent loss of fxn
Usually associated with starvation
128
Why do we see hepatic lipidosis so often in cats who are being fed kibble?
Because kibble has a lot of CHO which cats can't metabolize.
129
How can we decrease risk or prevent hepatic lipidosis?
Increase protein content in the diet
130
What cats are most at risk of developing hepatic lipidosis?
Obese cats
131
What signs do we see in hepatic lipidosis?
Vomiting, diarrhea, bleeding, icterus, ALKP increased
132
How do we treat hepatic lipidosis?
As soon as can, place a feeding tube to get nutrition into the cat
Supplement with L-carnitine, Taurine and Arginine
NOTE: L-carnitine assists mitochondrial fatty acid oxidation; Taurine important to conjugate bile acids; Arginine is part of the urea cycle
133
Why should you not force feed a cat with hepatic lipidosis?
Cat will develop a very strong food aversion
134
In dogs, drooling is often a sign of nausea. In cats, it means something else, what does it mean?
Sign of hepatic encephalopathy
135
What are 2 infectious causes of acute liver dz?
Infection canine hepatitis
| Lepto
136
Who do you see most commonly with ICH?
Young, unvaccinated dogs
137
What are the signs of ICH?
V&D, GI bleeding, glomeulonephritis
NOTE: ICH can be mistaken for Parvo
138
What is the hallmark feature of ICH?
Corneal edema
139
How do you dz lepto?
Serum titers
140
How do you treat lepto?
Abx
141
What do you need to remember about dogs with suspected lepto?
EVERYONE should be wearing PPE, highly zoonotic
142
How can you prevent shedding of lepto in urine?
Treat with a combo of penecillin and tetracycline
143
When might you see hepatic encephalopathy?
Acute or chronic liver dz
| PSS
144
How does an animal with hepatic encephalopathy present?
Mental dullness, stupor/coma
Disoriented, blindness
Head pressing, circling, ataxia
Sometimes seizures
NOTE: Cats will salivate, DO NOT assume this is nausea
145
What is hepatic encephalopathy?
A neurologic syndrome that is potentiall reversible
146
What 4 things are on your Ddx if you have hepatic encephalopathy?
Acute liver injury
PSS
Cirrhosis
Urea enzyme cycle deficiency
147
How does hepatic encephalopathy occur?
Circulating toxins cross the BBB
148
What 3 toxins may cause hepatic encephalopathy?
Aromatic amino acids
Ammonia
Benzodiazapine-like substances
149
Which toxin in hepatic encephalopathy is measurable?
Ammonia
150
What can hepatic encephalopathy progress to?
Cerebral edema and death
151
How can you prevent hepatic encephalopathy from progressing to cerebral edema and death?
Mannitol or hypertonic saline
152
What are 7 things that can aggravate hepatic encephalopathy?
High protein diet
GIT bleeding (most dangerous trigger, ulcers)
Constipation (prolonged GI transit)
Metabolic alkalosis or Hypokalemia (if no H+ available, no excretion of ammonia at the kidney)
Excess benzodiazepines (dog is sedate MUCH MUCH longer than anticipated)
Stored blood trasnfusion (RBCs produce ammonia)
153
How do you treat hepatic encephalopathy?
Prevent formation and absorption of toxic substances from GIT
Correct fluids, pH and electrolytes
Treat primary cause if possible
Supportive care
154
What general therapies would you use in acute cases of hepatic encephalopathy?
Retention enema with lactulose, Povidone iodine or Neomycin sulfate) **First thing you will do if emergency
Fluids & glucose & potassium CRI
Cleansing enema (every 6hrs)
Use ion-trapping effect of lactulose
Half-dose of metronidazole to kill bacteria responsible for producing ammonia
155
What is the "ion-trapping effect" of lactulose?
Keeps ammonia in ammonium form which is not absorbed.
156
What is the prognosis of acute hepatic dz?
Generally good if event was overcome, cause was removed, damage did not exceed 50% and damage didn't prevent regeneration
157
What is chronic liver dz?
No improvement for 6+ months, inflammation that progresses to fibrosis and cirrhosis
158
Do we often find the cause of chronic liver dz?
No
159
What 2 dog breeds commonly have copper associated chronic liver dz?
Bedlington terriers
| Westies
160
What breed commonly has idiopathic hepatic fibrosis?
Young GSD
NOTE: Fibrosis in these dogs extends across the entire lobule
161
What are 6 main categories for causes of chronic hepatic dz?
```
Copper associated
Idiopathic
Chronic cholangiohepatitis
Drug induced
Infectious
Vacuolar hepatopathies
```
162
What is chronic cholangiohepatitis?
Inflammation around the biliary tract
163
What are 3 drugs that cause chronic liver dz?
Anticonvulsants
Carprofen (labs)
Steroids
NOTE: Steroid hepatopathy is transient
164
When we say a steroid hepatopathy is transient, what does that mean?
When we stop the steroids, the liver is allowed to heal
165
What are some major infectious causes of chronic liver dz?
Infectious canine hepatitis
Lepto
Acidophil cell hepatitis
166
What are vacuolar hepatopathies usually?
Reactive hepatopathies
167
What are 3 causes for vacuolar hepatopathy?
DM
Hyperadrenocorticism
Storage dz
168
What 2 things are often in the vacuoles of vacuolar hepatopathy?
Fat
| Glycogen
169
T/F: Increased ALKP in a dog is an indication that we should investigate the liver.
False. Increased ALKP in a dog is NOT an indication to investigate the liver
170
If you have increase ALKP in a dog, what 2 systems should you focus on before the liver?
Endocrine system
GI
NOTE: ALKP is usually an innocent bystander in the dog
171
What are the first 2 cells to respond to injury around the portal triads?
Lymphocytes
| Plasma cells
172
Where does liver dz in the dog usually start?
Periportal rather than centrilobular
173
As liver dz progresses, what is the pathogenesis?
Damage progresses from periportal towards the central vein, results in distorted architechture
174
What causes hepatic fibrosis and cirrhosis?
It's secondary to inflammation
175
Who is responsible for hepatic fibrosis and cirrhosis?
Ito cells
176
How is hepatic fibrosis and cirrhosis formed?
Ito cells produce collagen -> excessive extracellular matrix is produced and that ECM affects hepatocyte function and sinusoidal blood flow
177
What effect does fibrosis and cirrhosis have on blood flow?
Less elasticity causes increased pressure, portal hypertension and we see acquired PSS
178
Where can fibrosis occur?
Any of the 3 acinar zones
179
What zone has the best prognosis if it develops fibrosis?
Zone 1
180
What does the liver look like grossly if it's got fibrosis and cirrhosis?
Nodular
181
T/F: Chronic hepatitis is a diagnosis.
True
182
What enzyme should you not ignore in predisposed dog breeds
ALT
183
What cells are involved with chronic hepatitis?
CD3+ lymphocytes
184
What age group is typically affected by chronic hepatitis?
4-7years
185
Is there a sex predisposition with chronic hepatitis?
Females more likely than males
186
What is the clue or chronic hepatitis?
Increased ALT
187
What can you do to try to diagnose chronic hepatitis early?
Screen all at risk dogs
188
What is the most common and sometimes only sign you would see with chronic hepatitis?
PU/PD
NOTE: Rest of signs are very general
189
If you suspect chronic hepatitis, why would you do a liver function test?
Because the clinical signs are so vague
190
If you have vague clinical signs, PU/PD and suspect chronic hepatitis, what 2 tests should you do?
US (Can often find microhepatica)
| Biopsy!!
191
What 6 general steps do you take to treat a chronic liver?
```
Treat underlying cause
Diet (only protein restrict in HE)
Treat inflammation
Prevent fibrosis
Supplement vitamins and micronutrients
Give antioxidants
```
192
How long would you give abx for in chronic liver dz?
2-3 months
NOTE: can use fluoroquinolones, clavamox or 1/2 dose metronidazole
193
If you have a copper storage issue, what 2 things can you use to treat?
Penicillamine
Zinc-gluconate (binds Cu in the diet nd excretes in intestines)
Both are chelators
NOTE: DO NOT use chelators unless confirmed storage dz or else you will deplete copper available to animal
194
When should you also be supplementing vitamins and micronutrients?
If the patient is clinically ill in hospital
195
What is the best antioxidant to use for the chronic liver?
SAMe (S-adenosil-L-methionine)
196
How does Ursadiol help chronic liver?
Promotes bile flow and targets T lymphoctes to prevent fibrosis
197
If you are treating with metronidazole, why do you only give half the dose in a liver patient?
Because they have altered drug metabolism (metronidazole is metabolized in the liver)
198
What are 3 other thins you might consider when treating chronic liver?
Coagulopaties (give vit. K, FFP)
GIT complication (ulcers)
Secondary infections
199
How does ascites form with chronic hepatitis?
Portal hypertension in the absence of severe hypoalbuminemia
200
What should you NOT do to a chronic hepatitis case with ascites?
Don't drain the fluid via abdominocentesis! Could be fatal. Can do for diagnostics, but bandage well!!!
Only exception is if animal is dyspneic, and even then only drain a little bit.
201
How do you manage ascites in a chronic hepatitis patient?
Spironolactone, then add furosemide
NOTE: Not furosemide right away because shifts fluids too fast and also causes K loss which will exacerbate HE!
202
How can you monitor the ascites?
Measure girth at L2
203
Once you stabilize your ascites patient, how can you help manage them?
Low sodium diet
204
What are 3 causes of feline inflammatory liver dz?
Suppurative cholangitis
Lymphocytic cholangitis
Lymphocytic portal hepatitis (flukes)
205
What is triaditis?
Hepatitis
Pancreatitis
Inflammatory bowel dz
206
Because cats get triaditis, what should you do?
Biopsy the triad!!! (US guided)
207
What US changes do you see with cholangitis?
Enlarged liver with mixed echogenicity (fibrosis)
Biliary tracts thickened (esp. common bile duct)
Common bile duct becomes tortuous
NOTE: These are hallmark for cholangitis, just can't tell which one yet.
208
When you find cholangitis on US, what would your next step(s) be?
Biopsy for dx
| Cholecystocentesis to completely empty gall bladder (reduce chance of leakage) and send bile for culture and cytology
209
What age do we typically see suppurative cholangitis and cholangiohepatitis?
Middle-age to older cats
210
What causes the hepatocyte necrosis in suppurative cholangitis and cholangiohepatitis?
Neutrophilic infiltrate into periportal space
211
What enzyme changes will you see with suppurative cholangitis and cholangiohepatitis?
Increased bilirubin, ALT, ALKP and GGT
212
What do you see on the hemogram with suppurative cholangitis and cholangiohepatitis?
Neutrophilic left shift
213
How do you treat suppurative cholangitis and cholangiohepatitis?
Broad spectrum abx
- Clavamox
- Cephalosporins
- Fluoroquinolones
NOTE: NO enrofloxacin in cats!
214
How long would you expect to have a cat in hospital with suppurative cholangitis and cholangiohepatitis?
7-14 days ICU
NOTE: Place a feeding tube
215
What are 3 other things (besides abx) that you would use with a cat who had suppurative cholangitis and cholangiohepatitis?
Vit. K
SAMe
UDCA (Ursadiol etc.)
216
What is the prognosis in suppurative cholangitis and cholangiohepatitis?
Fair, but difficult if triaditis
217
What is lymphocytic cholangitis?
Lymphocytic infiltrates
218
What cats would you expect to find lymphocytic cholangitis in?
Young cats
Persians
NOTE: US mean age is older than Japan's which is about 4yrs
219
What are the clinical signs of lymphocytic cholangitis?
Jaundice and ascites
Might still be eating
Hepatomegaly
Lymphadenopathy
220
What does lymphocytic cholangitis closely resemble?
FIP
221
How do you diagnose lymphocytic cholangitis?
Histopath!!
See increase ALT, ALKP, GGT
Hyperglobulinemia
Ascitic fluid is thick with high globulins
HISTOPATH IS THE ONLY WAY TO DX!!!
222
Besides FIP, what else would be on your Ddx for lymphocytic cholangitis?
Lymphoma
223
How do you treat lymphocytic cholangitis?
Methotrexate is DoC
Prednisolone
Chlorambucil (instead of azothiaprine - for dogs)
Immunosuppressives
224
What are the 2 functions of bile?
Digestion and absorption of fat
| Excretion of cholesterol and bilirubin
225
Describe drainage of the liver.
Canaliculi merge to form terminal bile ducts and progressively larger bile ducts -> hepatic duct -> cystic ducts -> common bile duct -> duodenum
226
How is bile released?
Protein and fat stimulate contraction of the gall bladder via cholecystikinin (CCK)
227
What can happen if bile isn't released?
Cholecystitis
| Biliary mucoceal
228
What is an important cause of bile dysmotility?
Hypothyroid
229
What is extrahepatic biliary obstruction (EHBO)?
Obstruction of flow of bile from the gall bladder into the duodenum.
230
What are 4 causes of EHBO?
Stricture
Intraluminal obstruction
Extrinsic compression
Various diseases
231
What is the most common cause o EHBO in dogs?
Pancreatitis
232
What are the 2 most common causes of EHBO in cats?
```
Tumors
Inflammatory dz (FIP)
```
233
What is a good differential for EHBO?
Choledocholithiasis (primary or secondary)
234
What are 3 less likely causes of EHBO?
Neoplasia
Chronic duodenitis
Rupture of gall bladder or ducts
235
What is the cardinal clinical sign of EHBO?
Icterus
236
What are the other 5 main signs of EHBO?
```
Abdominal pain
Mental dullness
Vomition
Dehydration
Anorexia
```
237
What blood chem results would help you diagnose EHBO?
Slight increase in total bilirubin
Increase in ALKP/GGT
Increase in cholesterol
238
Are RADs helpful in diagnosing EHBO?
Only if mineralized choeleliths present
239
What type of imaging is best for diagnosing EHBO?
US
240
What 3 things might you see on abdominal US of the gall bladder when EHBO is present?
Distended gall bladder
Dilated tortuous bile duct
Thickened gall bladder wall
241
What sort of hemogram would you expect with EHBO?
Inflammatory leukogram with left-shift
242
What might you also notice increased in the blood work of an EHBO patient?
Increased cholesterol
NOTE: Because of the obstruction, don't ignore possibility of this as well.
243
What sort of ultrasonographic changes do you see with EHBO?
Retrograde dilation of CBD and GB and tortuous CBD
NOTE: looks like "too many tube", if remains for 5-7 days you can see intrahepatic dilation.
244
What is the average diameter of the common bile duct in a cat?
2mm
245
What is the average diameter of the common bile duct in a dog?
3mm
246
How do you treat EHBO?
General supportive treatment
Surgery if obstruction or rupture
May require Abx on culture of bile
247
What is cholecystitis?
A non-obstructive inflammation of the gall bladder which could become necrotic.
248
There are 3 classes of cholecystitis, what are they?
Class I: No rupture
Class II: Bile peritonitis
Class III: Omental adhesion
249
How is each class of cholecystitis managed?
Class I: Medically (chronic management though, surgical will remove the issue)
Class II: Surgical
Class III: Surgical
250
What bacterial infection can progress to a necrotizing cholecystitis?
E. coli
251
What 2 bacteria can cause emphysematous cholecystitis?
E. coli and Clostridum
252
How do you diagnose cholecystits?
RADs or US (better)
253
What can you do with a case of cholecystitis to figure out the cause?
Percutaneous US guided cholecystocentesis for C&S
254
What can you do for a case of cholecystitis to minimize risk?
Drain completely
255
What 3 things should you check before you perform a cholecystectomy?
Is there an inflammatory leukogram? (Give broad spectrum Abx)
Is patient hypotensive? (if yes, stabilize)
Is patient hypokalemic? (if yes, associated with worse outcome)
256
What is the progression of a biliary mucocele?
Too much fat + not enough fiber = cholesterol accumulates
Inflammation + abnormal absorption = Cholesterol precipitates
NOTE: Often, owners think this is a cholelith, but these are rare in dogs
257
What is a biliary mucocele?
Abnormally distended gall bladder with mucous and congealed bile salts
258
How is a biliary mucocele confirmed?
Non-dependent sludge on US
259
What breed is at risk of developing a biliary mucocele?
Shetland sheepdogs
260
What endocrinopathy is a risk factor to developing a biliary mucocele?
Hyperadrenocorticism
261
What is a major risk factor to developing a biliary mucocele?
Hyperlipidemia
262
What sort of clinical signs will you see with a biliary mucocele?
Non-specific signs
Concurrent pancreatitits (miniature schnauzer)
Icterus if sludge is obstructing CBD
Often an incidental finding (Shetlands/HAC)
263
What 4 things would you expect to see on your lab results with a biliary mucocele?
Severely elevated liver enzymes***
Hypercholesterolemia
Hypertriglyceridemia
Hyperbilirubinemia
264
How can you obtain a definitive diagnosis of a biliary mucocele?
Abdominal US
NOTE: can also exclude other etiologies of acute vomiting and can evaluate the CBD
265
What is a hallmark sign of necrosis in the gallbladder on US?
Edema
266
What are 2 things that signify edema in the gall bladder on US?
Lamellation (strips)
| Wall is thickened
267
What 3 things might you see on US that signify a gall bladder rupture?
Discontinuity of the wall
Free fluid
Surrounding fat is hyperechoic
268
What is the definitive treatment for a biliary mucocele?
Surgery
269
What should you be sure to take with you when you surgically remove the gall bladder?
Two pieces of the liver from the left and right side along with a biopsy of the gall bladder.
This is because if the patient has a chronic cholangiohepatitis, you're going to want to know about it.
270
When you remove a gall bladder, what should you do with the bile?
Send for aerobic and anaerobic culture
271
What is a very important surgical rule of thumb when removing a gall bladder?
Ensure the CBD is still patent or else you won't have any way to allow drainage of the liver.
272
Why is medical management of a biliary mucocele not very effective?
Because we are unable to convert the semi-solid mucocele into liquid bile
273
Why should you also treat biliary mucocele patients with Ursodiaol?
It promotes choleresis by cholehepatic shunting
NOTE: Choleresis = The secretion of bile by the liver into the gallbladder.
274
Why would you treat a biliary mucocele patient with SAMe?
Need to protect the liver as well, so good to give antioxidant
275
What comordib dzs do biliary mucocele patients sometimes have?
Bile peritonitis and pancreatitis
276
What 2 things do you do in cases of biliary mucocele which also have bile peritonitits and pancreatitis?
Address hypotensive shock
| Supportive care for the peritonitis and pancreatitis
277
How does a gall bladder rupture affect the outcome of the patient?
It doesn't, hypotensive shock is what you need to be worried about
278
How common are primary hepatobiliary neoplasias?
Uncommon
279
What 4 tumors can send mets to the hepatobiliary system?
Lymphoma
Pancreatic adenocarcinoma
Hemangiosarcoma
Intestinal sarcoma
280
What type of hepatobiliary neoplasia is benign in old cats?
Biliary cystadenoma
281
54% of all primary tumors in the dog are hepatocellular carcinomas, where do these almost always start in the liver?
Left lateral lobe
282
Hepatobiliary neoplasias can be clinically silent, how do you often pick them up in geriatric dogs?
Increased ALKP
Don't ignore ALKP in a geriatric dog
283
What are 3 ways you can diagnose hepatobiliary neoplasias?
US
FNA
Biopsy**
284
What is the prognosis usually in hepatobiliary neoplasias?
Poor
