Feline Liver Disease Flashcards
What 3 diseases are more common in cats than dogs?
- Biliary tract disease
- Pancreatitis
- IBD
What is the relationship anatomically between the pancreatic duct, duodenum and the CBD?
•pancreatic duct joins the CBD before reaching the duodenum in most cats
What are the metabolic difference between dogs and cats?
- ineffective glucuronidation pathway reduces ability to metabolise drugs and toxins
- more susceptible to toxic damage
- sensitive to many hepatotoxic drugs
What does hepatic gluconeogensis rely on in cats?
What is the significance of this?
Protein - way of controlling blood sugar and therefore energy
What 2 things MUST cats have in their diet and why is this?
- Arginine - if deficient, NH3 rises
- Taurine - essential for the conjugation of bile salts
Due to the cat’s liver pathological processes being different, what 2 diseases do cats rarely get?
- Severe fibrosis
- Cirrhosis
=Portal hypertension and acquired portosystemic shunts are uncommon
What disease are cats especially susceptible due to the pathological processes?
Hepatic lipidosis
A) Is primary or secondary hepatic lipidosis rare in dogs?
B) Which is clinically significant in cats?
A) Primary
B) Secondary
What 3 diseases can be underlying secondary hepatic lipidosis?
diabetes mellitus
Pancreatitis
IBD
What is “fat cat revenge” in secondary hepatic lipidosis?
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.
What are the non-specific clinic signs of liver disease (6)
- Lethargy
- Change in appetite
- Inappetance?
- Polyphagia
- Weight loss
- BCS often reflects duration of disease
- Vomiting
- Polyuria and polydipsia
- Pyrexia
What2 diseases do liver disease clinical signs overlap with?
- IBD
- Pancreatitis
What 3 clinical signs are more specific to liver disease?
- Jaundice
- Ascites
- Hepatomegaly
What are the 2 categories of primary inflammatory liver disease?
- acute neutrophilic (suppurative) cholangitis
- previously/sometimes referred to as acute/suppurative cholangiohepatitis
- chronic lymphocytic cholangitis
- previously/sometimes referred to as chronic/non suppurative cholangiohepatitis
What is the signalment for Acute neutrophilic (suppurative) cholangitis?
Youn/middle ages cats
What are the clinical signs seen with Acute neutrophilic (suppurative) cholangitis?
- 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
What is seen on physical exam with Acute neutrophilic (suppurative) cholangitis? (4)
- dehydration
- pyrexia
- jaundice
- abdominal discomfort
What is the cause of acute neutrophilic (suppurative) cholangitis? (2)
- ascending bacterial infection
- E Coli from SI is most common
- mixed infection from other commensals is not unusual
- concurrent disease common
- IBD
- pancreatitis
What can Acute neutrophilic (suppurative) cholangitis be complicated by?
Hepatic lipidosis
What is the signalment of Chronic lymphocytic cholangitis?
Varied age
Persians predisposed
What are the clinical signs of Chronic lymphocytic cholangitis? (4)
- wax and wane
- often bright and alert
- weight loss
- appetite variable
- intermittent anorexia/lethargy
- appetite can be normal or increase
What can be seen on physical exam of chronic lymphocytic cholangitis? (3)
- ascites?
- jaundice
- hepatomegaly
What is the cause of Chronic lymphocytic cholangitis?
- unknown
- immune mediated?
- persistent infection if any neutrophilic component to the inflammation?
What is the signalment for heepatic lipidosis?
- Increased risk in obese
What are the clinical signs of Hepatic lipidosis?(5)
- weight loss
- anorexia
- vomiting/nausea/ptyalism
- diarrhoea
- lethargy= depression/HE
What can be seen on physical exam with hepatic lipidois (3)
- jaundice
- signs of HE
- evidence of coagulopathy?
What is the cause of hepatic lipidosis?
- any cause of sudden loss of appetite
- pancreatitis
- IBD
- cholangitis
- starvation
- excessive peripheral mobilisation of lipid
What can be seen here?
What else can we do?
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.
What is the level of bilirubin before we pick it up clinically?
>50umol/L
What does it mean if a cat has bilirubinuria?
Significant!
Why may tissue still be yellow after bilirubinaemia resolves?
Takes a while for pigment to clear
What are the differential diagnosis for pre-hepatic jaundice in a cat? Split into immune mediated (2) and non immune mediated (3)
- immune mediated:
- primary IMHA
- secondary IMHA
- FIV/FeLV
- non immune mediated
- Mycoplasma hemofelis
- hypophosphataemia
- oxidative damage
- HB anaemia
- onion toxicity
What does mild to moderate anaemia mean in a jaundiced cat?
It is more likely to reflect the underlying chronic or inflammatory disease. Don’t over interpret anaemia as the cause of the jaundice.
What are the differentials for hepatic jaundice in cats? (7)
- 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
What is hepatic jaundice usually associated with? (rather than redcued liver function)
Intrahepatic cholestasis
Name differential diagnosis for post hepatic jaundice in cats (6)
- pancreatitis
- cholecystitis
- cholelithiasis
- often associated with neutrophilic cholangitis
- hepatobiliary mass
- duodenal mass
- trauma àruptured biliary tract
EHBDO: extrahepatic bile duct obstruction:
What should you do?
What is seen?
What is the bilirubin level?
- 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?
What are the differentials for ascites in cats? (6)
- Blood
- Urine
- Bile
- Transudate
- Modified transudate
- Exudate
What 2 disease share many clinical features including ascites?
- FIP
- Lymphocytic cholangitis
What are the differentials for weight loss and polyphagia in cat? (4)
- Malabsorption/maldigestion
- Inflammatory bowel disease,
- Exocrine pancreatic insufficiency
- Intestinal lymphoma
- Endocrine disorders
- Diabetes mellitus
- Hyperthyroidism
- Neoplasia
- Lymphocytic cholangitis
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
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
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
When are bile acids not useful?
When the animal is already jaundiced
What are the liver ultrasound findings in Neutrophilic cholangitis?
- thickened gallbladder wall?
- BD distended?
- bile sludging
- patchy echogenicity
- choleliths?
- acoustic shadowing
What are the liver ultrasound findings in lymphocytic cholangitis?
- 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
What are the liver ultrasound findings in hepatic lipidosis?
- 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
What do we check prior to a liver biopsy and how do we do this?
- prothrombin time (PT) AKA OSPT
- activated partial thromboplastin time (APTT)
- Check platelets on a blood smear in case any risk of DIC
What can we administer 24 hours before a biopsy?
Vitamin K
What are the reasons behind avoiding trucut biopsies for the liver? (3)
- 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
How can we make a diagnosis of acute neutrophilic cholangitis?
- 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
How can you make a diagnosis of chronic lymphocytic cholangitis?
- Cytology and culture not consistent with infection (bile and liver)
- Liver biopsy= lymphocytic infiltrate in portal areas & biliary duct proliferation
- Main differential lymphoma
How can we diagnose hepatic lipidosis?
- 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
- Ultrasound guided aspirate safer than biopsy
How can we plan ahead in a cat with hepatic lipidosis undergoing a GA?
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
What 4 things can decsions about the most likely diagnosis be based on?
- Signalment
- History
- Physical exam
- Clinical pathology results
How can we treat neutrophilic cholangitis? (5)
- 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
What is the prognosis of Neutrophilic cholangitis?
Excellent - make a full recovery
How can we treat Lymphocytic cholangitis? (5)
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
What is the prognosis of Lymphocytic cholangitis?
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
How can you treat hepatic lipidosis? (6)
- 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…
What is the prognosis of hepatic lipidosis?
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!!!
Name 5 diseases which could could secondary hepatopathy in cats (6)
- 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!
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) Older animals
B)
- liver parenchyma
- hepatocellular carcinoma
- bile duct
- biliary duct adenoma
- maybe diffuse/nodular
C) metastases
D) lymphoma
What are the differentials for hepatic neoplasia? (2)
- Chronic pancreatitis
- Hepatic cyst
What is the approach to a suspect hepatic neoplasia?
- 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
What type of portosystemic shunt may a cat get?
CONGENITAL
What are the clinical signs of Portosystemic shunts (7)
- 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
How can we diagnose Portosystemic shunts? (4)
- 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)
How can we manage Portosystemic shunts medically? (3)
medical
- used to advise restrict protein but don’t!
- add cottage cheese, eggs and rice
- antibiotics
- metronidazole
- neomycin
- lactulose
What is the ideal management technique for a Portosystemic shunt?
- surgical
- treatment of choice
- stabilise medically first
- beware of the post operative period
- challenging sometimes
- May seizure in post op – not great
What is the best way to diagnose liver disease?
Biopsy
What trial treatment may be warranted? (2)
- Antibiotics
- Steroids
