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Small Animal Final Year > Feline Liver Disease > Flashcards

Feline Liver Disease Flashcards

1
Q

What 3 diseases are more common in cats than dogs?

A
  • Biliary tract disease
  • Pancreatitis
  • IBD
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2
Q

What is the relationship anatomically between the pancreatic duct, duodenum and the CBD?

A

•pancreatic duct joins the CBD before reaching the duodenum in most cats

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3
Q

What are the metabolic difference between dogs and cats?

A
  • ineffective glucuronidation pathway reduces ability to metabolise drugs and toxins
  • more susceptible to toxic damage
  • sensitive to many hepatotoxic drugs
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4
Q

What does hepatic gluconeogensis rely on in cats?

What is the significance of this?

A

Protein - way of controlling blood sugar and therefore energy

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5
Q

What 2 things MUST cats have in their diet and why is this?

A
  • Arginine - if deficient, NH3 rises
  • Taurine - essential for the conjugation of bile salts
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6
Q

Due to the cat’s liver pathological processes being different, what 2 diseases do cats rarely get?

A
  • Severe fibrosis
  • Cirrhosis

=Portal hypertension and acquired portosystemic shunts are uncommon

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7
Q

What disease are cats especially susceptible due to the pathological processes?

A

Hepatic lipidosis

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8
Q

A) Is primary or secondary hepatic lipidosis rare in dogs?

B) Which is clinically significant in cats?

A

A) Primary

B) Secondary

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9
Q

What 3 diseases can be underlying secondary hepatic lipidosis?

A

diabetes mellitus

Pancreatitis

IBD

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10
Q

What is “fat cat revenge” in secondary hepatic lipidosis?

A

If you see a fat cat and decide it needs a diet. Be careful how you council owners – may put on a very strict diet; possible protein malnutrition and mobilise fat store = hepatic liver and become very unwell. Crash diets – car crash.

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11
Q

What are the non-specific clinic signs of liver disease (6)

A
  • Lethargy
  • Change in appetite
  • Inappetance?
  • Polyphagia
  • Weight loss
  • BCS often reflects duration of disease
  • Vomiting
  • Polyuria and polydipsia
  • Pyrexia
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12
Q

What2 diseases do liver disease clinical signs overlap with?

A
  • IBD
  • Pancreatitis
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13
Q

What 3 clinical signs are more specific to liver disease?

A
  • Jaundice
  • Ascites
  • Hepatomegaly
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14
Q

What are the 2 categories of primary inflammatory liver disease?

A
  • acute neutrophilic (suppurative) cholangitis
    • previously/sometimes referred to as acute/suppurative cholangiohepatitis
  • chronic lymphocytic cholangitis
    • previously/sometimes referred to as chronic/non suppurative cholangiohepatitis
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15
Q

What is the signalment for Acute neutrophilic (suppurative) cholangitis?

A

Youn/middle ages cats

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16
Q

What are the clinical signs seen with Acute neutrophilic (suppurative) cholangitis?

A
  • usually acute onset
  • anorexia/food aversion
    • Cats will go to their food, but then they walk away when an O has given something just to see what it is (cf dog who will not eat at all)
  • vomiting/nausea
  • diarrhoea
  • lethargy
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17
Q

What is seen on physical exam with Acute neutrophilic (suppurative) cholangitis? (4)

A
  • dehydration
  • pyrexia
  • jaundice
  • abdominal discomfort
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18
Q

What is the cause of acute neutrophilic (suppurative) cholangitis? (2)

A
  • ascending bacterial infection
    • E Coli from SI is most common
    • mixed infection from other commensals is not unusual
  • concurrent disease common
    • IBD
    • pancreatitis
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19
Q

What can Acute neutrophilic (suppurative) cholangitis be complicated by?

A

Hepatic lipidosis

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20
Q

What is the signalment of Chronic lymphocytic cholangitis?

A

Varied age

Persians predisposed

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21
Q

What are the clinical signs of Chronic lymphocytic cholangitis? (4)

A
  • wax and wane
  • often bright and alert
  • weight loss
  • appetite variable
  • intermittent anorexia/lethargy
  • appetite can be normal or ­increase
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22
Q

What can be seen on physical exam of chronic lymphocytic cholangitis? (3)

A
  • ascites?
  • jaundice
  • hepatomegaly
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23
Q

What is the cause of Chronic lymphocytic cholangitis?

A
  • unknown
  • immune mediated?
  • persistent infection if any neutrophilic component to the inflammation?
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24
Q

What is the signalment for heepatic lipidosis?

A
  • Increased risk in obese
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25
Q

What are the clinical signs of Hepatic lipidosis?(5)

A
  • weight loss
  • anorexia
  • vomiting/nausea/ptyalism
  • diarrhoea
  • lethargy= depression/HE
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26
Q

What can be seen on physical exam with hepatic lipidois (3)

A
  • jaundice
  • signs of HE
  • evidence of coagulopathy?
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27
Q

What is the cause of hepatic lipidosis?

A
  • any cause of sudden loss of appetite
    • pancreatitis
    • IBD
    • cholangitis
  • starvation
  • excessive peripheral mobilisation of lipid
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28
Q

What can be seen here?

What else can we do?

A

Jaundiced cats: a few top tips – can be particular tricky- especially ginger
Look at urine – bilirubin is deffo abnormal in a cat
Key sites for detecting jaundice in cats- the hard palate can also be a good place to look.

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29
Q

What is the level of bilirubin before we pick it up clinically?

A

>50umol/L

30
Q

What does it mean if a cat has bilirubinuria?

A

Significant!

31
Q

Why may tissue still be yellow after bilirubinaemia resolves?

A

Takes a while for pigment to clear

32
Q

What are the differential diagnosis for pre-hepatic jaundice in a cat? Split into immune mediated (2) and non immune mediated (3)

A
  • immune mediated:
    • primary IMHA
    • secondary IMHA
      • FIV/FeLV
  • non immune mediated
    • Mycoplasma hemofelis
    • hypophosphataemia
    • oxidative damage
      • HB anaemia
      • onion toxicity
33
Q

What does mild to moderate anaemia mean in a jaundiced cat?

A

It is more likely to reflect the underlying chronic or inflammatory disease. Don’t over interpret anaemia as the cause of the jaundice.

34
Q

What are the differentials for hepatic jaundice in cats? (7)

A
  • inflammatory liver disease
    • acute neutrophilic cholangitis
    • chronic lymphocytic cholangitis
  • hepatic lipidosis (**bilirubin can be >200 umol/l)
  • FIP
  • Lymphoma (never think sick cat without thinking lymphoma)
  • hepatotoxicity
    • paracetamol, carbimazole/methimazole, diazepam
  • amyloidosis
  • Sepsis – then jaundice is just going to be part of the inflammatory response
35
Q

What is hepatic jaundice usually associated with? (rather than redcued liver function)

A

Intrahepatic cholestasis

36
Q

Name differential diagnosis for post hepatic jaundice in cats (6)

A
  • pancreatitis
  • cholecystitis
  • cholelithiasis
    • often associated with neutrophilic cholangitis
  • hepatobiliary mass
  • duodenal mass
  • trauma àruptured biliary tract
37
Q

EHBDO: extrahepatic bile duct obstruction:

What should you do?

What is seen?

What is the bilirubin level?

A
  • EHBDO can be a surgical emergency:
  • bilirubin often> 250 μmol/l
  • Severe jaundice, poorly, ascites, not ticking inflammatory liver disease then consider U/S and look at GB, CBD to look for this.
  • If there is any fluid in the abdomen – tap it and look for any bilirubin
  • ultrasound diagnosis:
  • gall bladder and common bile duct grossly distended
  • Intra hepatic bile ducts obvious?
38
Q

What are the differentials for ascites in cats? (6)

A
  • Blood
  • Urine
  • Bile
  • Transudate
  • Modified transudate
  • Exudate
39
Q

What 2 disease share many clinical features including ascites?

A
  • FIP
  • Lymphocytic cholangitis
40
Q

What are the differentials for weight loss and polyphagia in cat? (4)

A
  • Malabsorption/maldigestion
    • Inflammatory bowel disease,
    • Exocrine pancreatic insufficiency
    • Intestinal lymphoma
  • Endocrine disorders
    • Diabetes mellitus
    • Hyperthyroidism
  • Neoplasia
  • Lymphocytic cholangitis
41
Q

What are the following parameters in Neutrophilic cholangitis?

Haematology

ALT

ALP (any ­ is significant)

GGT (comes from lower in the GI tract)

Bilirubin

Globulins

Other findings

A
42
Q

What are the following parameters in lymphocytic cholangitis?

Haematology

ALT

ALP (any ­ is significant)

GGT (comes from lower in the GI tract)

Bilirubin

Globulins

Other findings

A
43
Q

What are the following parameters in hepatic lipidosis?

Haematology

ALT

ALP (any ­ is significant)

GGT (comes from lower in the GI tract)

Bilirubin

Globulins

Other findings

A
44
Q

When are bile acids not useful?

A

When the animal is already jaundiced

45
Q

What are the liver ultrasound findings in Neutrophilic cholangitis?

A
  • thickened gallbladder wall?
  • BD distended?
  • bile sludging
  • patchy echogenicity
  • choleliths?
    • acoustic shadowing
46
Q

What are the liver ultrasound findings in lymphocytic cholangitis?

A
  • hepatomegaly common
  • heterogeneous appearance to the liver so there will only be subtle changes
  • irregular margins,
  • ascites quite common as they are more chronic
  • +/- mesenteric lymphadenopathy
47
Q

What are the liver ultrasound findings in hepatic lipidosis?

A
  • hyperechoic appearance (bright white) – as it has fat in it
    • Fairly non-specific? Lymphoma too?
    • A normally looking U/S does not rule it out
48
Q

What do we check prior to a liver biopsy and how do we do this?

A
  • prothrombin time (PT) AKA OSPT
  • activated partial thromboplastin time (APTT)
  • Check platelets on a blood smear in case any risk of DIC
49
Q

What can we administer 24 hours before a biopsy?

A

Vitamin K

50
Q

What are the reasons behind avoiding trucut biopsies for the liver? (3)

A
  • friable tissue (especially those with lipidosis! Would worry it will disintergrate)
  • very small sample (may not have enough; including portal triad)
  • other tissue samples often needed (pancreas, intestine, LN)
    • Best diagnosis – lapartotomy to get all these samples. But this is a fairly major procedure to put a sick cat through
51
Q

How can we make a diagnosis of acute neutrophilic cholangitis?

A
  • Cytology and culture of bile should be definitive
    • Ultrasound guided aspirates?
  • Liver biopsy
    • Might be non specific mild changes
    • Neutrophilic infiltrate (the starting point is the bile duct lumen) within the bile duct lumen and/or epithelium
    • Periportal necrosis is common
52
Q

How can you make a diagnosis of chronic lymphocytic cholangitis?

A
  • Cytology and culture not consistent with infection (bile and liver)
  • Liver biopsy= lymphocytic infiltrate in portal areas & biliary duct proliferation
    • Main differential lymphoma
53
Q

How can we diagnose hepatic lipidosis?

A
  • Cytology
    • Ultrasound guided aspirate safer than biopsy
      • Often poor anaesthetic risk
    • Evidence of severe lipid accumulation in hepatocytes
      • Don’t confuse with mild 2ry lipidosis
    • Can help to rule out lymphoma
54
Q

How can we plan ahead in a cat with hepatic lipidosis undergoing a GA?

A

Sedation/GA used for liver aspirate then think about a feeding tube at the same time

This is important for the treatment and management of the cat; as time ticks of the liver will get worse

55
Q

What 4 things can decsions about the most likely diagnosis be based on?

A
  • Signalment
  • History
  • Physical exam
  • Clinical pathology results
56
Q

How can we treat neutrophilic cholangitis? (5)

A
  • Appropriate antibiotic
    • 4-6 week course
    • amoxicillin is a good 1st choice or if no diagnostics
  • Ursodeoxychilic acid – supports the patient
    • choleretic effects
    • anti inflammatory properties/immune modulatory properites (describe to owners as anti-inflammatory but it is immune modulatory)
    • Displace hydrophobic bile acids
  • Anti oxidants
  • Supportive care if sick (can be septicà SIRSà MODS)
    • IVFT +/- potassium, glucose
  • Enteral nutrition to avoid hepatic lipidosis as a complication
    • “IBD diet” or high protein critical care diet
    • don’t protein restrict
57
Q

What is the prognosis of Neutrophilic cholangitis?

A

Excellent - make a full recovery

58
Q

How can we treat Lymphocytic cholangitis? (5)

A

Best treatment not clear because underlying cause not known – probably anti-inflammatory or immune-suppression is the way to go.

  • Corticosteroid (+/- chlorambucil as 2nd agent (back up immunosuppressive for cats not in dogs))
    • immune suppressive doses
    • manage acute flare ups but tends to recur
    • doesn’t interfere with biochemical monitoring (does in dogs)
    • Don’t get the isoenzymes
    • Don’t get the fibrosis like in dogs
  • Antibiotic treatment
    • rule out infection if you can do diagnostics?
    • Early stages to see if there is an improvement
  • Ursodeoxycholic acid
  • Antioxidants (bile is a potent oxidising toxin in the liver)
    • sAMe
    • vitamin E
  • Enteral nutrition
  • Supportive care
59
Q

What is the prognosis of Lymphocytic cholangitis?

A

Prognosis: waxing and waning disease continues but rarely fatal

*Cats don’t progress disease with fibrosis the way dogs do*

Easier to monitor – if the liver enzymes improve we are under control

60
Q

How can you treat hepatic lipidosis? (6)

A
  • Enteral feeding ASAP – tube feeding
    • continue for 4-6 weeks
    • Keep the tube until you are absolutely sure!
  • Anti emetics +/- prokinetics
    • maropitant, metoclopramide
    • ranitidine
  • IVFT
    • monitor potassium and glucose
  • Antioxidants
  • Vitamin K
    • if any evidence of coagulopathy
    • Less easy to give fresh plasma like in dogs as this is not as available
  • Treat the underlying cause/concurrent disease
    • E.g. pancreatitis or neutrophilic con…
61
Q

What is the prognosis of hepatic lipidosis?

A

Prognosis: can be good but some cats are very poorly…..

They can crash and burn within 24 hours

Acutely unwell… be sure to manage the owner expectation!!!

62
Q

Name 5 diseases which could could secondary hepatopathy in cats (6)

A
  • Hyperthyroidism
    • Treat this and then see what the liver enzymes do
    • Don’t need to liver biopsy
    • Diabetes Mellitus
  • Toxic
  • GI disease
  • Pancreatitis
  • Lymphoma
    • always important to consider in cats!
63
Q

Hepatic neplasia:

A) Age?

B) Where is primary liver neoplasia common? (3)

C) What is it a common site for?

D) What systemic neoplasia could it be?

A

A) Older animals

B)

  • liver parenchyma
    • hepatocellular carcinoma
  • bile duct
    • biliary duct adenoma
  • maybe diffuse/nodular

C) metastases

D) lymphoma

64
Q

What are the differentials for hepatic neoplasia? (2)

A
  • Chronic pancreatitis
  • Hepatic cyst
65
Q

What is the approach to a suspect hepatic neoplasia?

A
  • Signalment
  • History
  • Physical exam
  • Diagnostic imaging:
    • radiography/ultrasound
    • assess primary
    • look for mets or involvement of other organs if suspect lymphoma
      • thoracic imaging
  • Biopsy for a diagnosis
    • ultrasound guided
    • exploratory laparotomy
      • might be able to combine assessment and treatment
  • Treatment = surgery unless lymphoma
66
Q

What type of portosystemic shunt may a cat get?

A

CONGENITAL

67
Q

What are the clinical signs of Portosystemic shunts (7)

A
  • small- “runty-shunty”
  • seizures
    • intermittent
    • complete/partial
  • dull/manic hehaviour
  • ptyalism
  • poor anaesthesia recovery
    • at neutering?
    • This cat may not really wake up from the GA
    • Must always take a good history when you admit!!!! May look skinny – but most 6mo cats are!
    • Will need a lot of post op care
    • Consider bile acid tests as the bloods will look normal
  • PU/PD
  • copper-coloured iris
68
Q

How can we diagnose Portosystemic shunts? (4)

A
  • history and physical exam
  • blood results
    • high bile acids
    • microcytic anaemia
    • (high ammonia)
  • ultrasound may demonstrate shunt (but this is more of a specialist technique)
  • portal-venography (most often extrahepatic)
69
Q

How can we manage Portosystemic shunts medically? (3)

A

medical

  • used to advise restrict protein but don’t!
  • add cottage cheese, eggs and rice
  • antibiotics
  • metronidazole
  • neomycin
  • lactulose
70
Q

What is the ideal management technique for a Portosystemic shunt?

A
  • surgical
  • treatment of choice
  • stabilise medically first
  • beware of the post operative period
  • challenging sometimes
  • May seizure in post op – not great
71
Q

What is the best way to diagnose liver disease?

A

Biopsy

72
Q

What trial treatment may be warranted? (2)

A
  • Antibiotics
  • Steroids

Small Animal Final Year (317 decks)

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