hepatobiliary 3: more cholangitis, hepatic lipidosis, etc.

Question 1

Lymphocytic Cholangitis cause

Answer 1

• Cause unknown
• Immune mediated?
• Transient infection causing immune stimulation and hepatic inflammation?

Question 2

Lymphocytic Cholangitis history

Answer 2

Often lengthy history of intermittent clinical signs, slowly progressive

Question 3

Lymphocytic Cholangitis signalment

Answer 3

– any age, breed, sex

Question 4

Lymphocytic Cholangitis Clinical signs

Answer 4

• Clinical signs of long-term, low grade illness
  > Weight loss, decreased appetite, vomiting, PU/PD, lethargy
  >Possible icterus
  > Intermittent signs – might be BAR on presentation
• Concurrent illness (pancreatitis, IBD) can be apparent

Question 5

Lymphocytic Cholangitis: Presentation on PE

Answer 5

• Poor body condition
• Hepatomegaly
• Ascites in 1/3 of cats (high protein fluid)
• Possible signs of hepatic encephalopathy
• Pyrexia not common

Question 6

Lymphocytic Cholangitis: CBC

Answer 6

CBC generally normal
* Can see mild non regenerative anemia

Question 7

Lymphocytic Cholangitis: biochem? vs neutrophilic cholangitis?

Answer 7

• Increased ALT and/or ALP in ~50%
• Hyperbilirubinemia ~ 30%
• Hyperglobulinemia ~40-50%
• Hypoalbuminemia ~ 10-30%
• ALT and bilirubin tend to be of lower magnitude elevations than neutrophilic cholangitis

Question 8

Lymphocytic Cholangitis: abdominal fluid

Answer 8

• Can be moderate to marked
• High protein content, small lymphocytes/inflammation

Question 9

Aside from lymphocytic cholangitis, What’s another differential for high globulins, low albumin, abdominal effusion (high protein)?

Answer 9

• Feline infectious peritonitis (FIP)

Question 10

Lymphocytic Cholangitis: radiographs

Answer 10

• Hepatomegaly, ascites evident on
  radiographs

Question 11

lymphocytic cholangitis ultrasound findings

Answer 11

possible findings:
* Normal to coarse hepatic echotexture
* Abdominal lymphadenomegaly
* Ascites
* Gall bladder and biliary tracts: normal or dilated tracts, sludge GB
* Concurrent pancreatitis / enteropathy

Question 12

Lymphocytic Cholangitis Clinical features can overlap with:

Answer 12

FIP, hepatic lymphoma, neutrophilic cholangitis

Question 13

lymphocytic cholangitis Definitive diagnosis requires

Answer 13

Definitive diagnosis requires biopsy
* Portal lymphocytic infiltration
* Ductopenia
* Peribiliary fibrosis

Question 14

Lymphocytic Cholangitis: Treatment

Answer 14

Supportive care:
* Hospitalization and nutritional support might be required
* Antiemetics, appetite stimulant
* Abdominocentesis if marked ascites (comfort)

If signs of HE:
* Lactulose, metronidazole

If signs of coagulopathy or biopsy considered: * Vitamin K
()
* Prednisolone 1-2 mg/kg/day
> No difference in outcome: 1 mg/kg/day versus 2 mg/kg/day in one study
* Ursodiol
> Can combine with prednisolone
> One small study – shorter survival when ursodiol used instead of prednisolone

Question 15

Lymphocytic Cholangitis: Prognosis

Answer 15

• Long term
  > Monitor liver values, clinical signs
  > Consider tapering prednisolone to ~1 mg/kg if starting higher
• Complications not common
• Reported survival times 2-3 years, but small studies
  > No cure, recurrence possible

Question 16

Hepatic Lipidosis predisposing factors

Answer 16

• Negative energy balance usually the predisposing factor
• Clinically, 2-14 days of anorexia precedes HL
• Obesity can predispose

Question 17

primary vs secondary hepatic lipidosis - what are they and which is most common?

Answer 17

PrimaryHL:
* Healthy animal has decreased access to food / palatable food, decreased intake secondary to stress

Secondary HL (most common):
* Anorexiasecondarytounderlyingdisease
* E.g., pancreatitis, diabetes mellitus, primary hepatobiliary disease, IBD, neoplasia

Question 18

Hepatic Lipidosis: Pathophysiology, definition

Answer 18

• Negative energy balance alters lipid metabolism
• Triglycerides accumulate in liver
• Defined by triglycerides in >80% of hepatocytes; >50% increase in liver weight
• Functional impairment of liver, intrahepatic cholestasis
• Nutritional deficiencies caused by anorexia can be important in lipid metabolism
  > Methionine, carnitine, taurine
  > Arginine can contribute to encephalopathy

Question 19

Common underlying or concurrent diseases for hepatic lipidosis

Answer 19

> Pancreatitis, diabetes mellitus, primary hepatobiliary disease, IBD, neoplasia

Question 20

Hepatic Lipidosis: signalment and risk factors

Answer 20

• Any age, breed; often middle-aged to older
• Risk factors: obesity, stressful event/illness

Question 21

Hepatic Lipidosis Clinical signs & examination

Answer 21

• Lipidosis and inciting event can have similar signs
• Icterus, vomiting
• Signs of acute hepatic loss = encephalopathy (ptyalism in cats!)
• Hepatomegaly, loss of muscle mass but retaining fat

Question 22

Hepatic Lipidosis: Diagnosis
- enzymes

Answer 22

• Elevated bilirubin in almost all cases
• Elevated ALT, AST, ALP very common
  > ALP elevation especially significant in cats (very short half-life, and no steroid-induced ALP in this species)
• GGT often not elevated with purely HL
  > Could be elevated with concurrent biliary disease
• Markers of liver dysfunction
  > Decreased urea most commonly (~50% of cases)

Question 23

Hepatic Lipidosis: Diagnosis
- electrolytes

Answer 23

• Electrolyte derangements (low K, P, Mg)

Question 24

Hepatic Lipidosis: Diagnosis
- CBC

Answer 24

• CBC: anemia common

Question 25

Hepatic Lipidosis: Diagnosis
- coagulopathy?

Answer 25

common

Question 26

Laboratory abnormalities for hepatic lipidosis can reflect what?

Answer 26

can reflect underlying disease
* E.g., elevated lipase with pancreatitis

Question 27

Hepatic Lipidosis: Diagnosis
- radiographs

Answer 27

Radiographs can show hepatomegaly

Question 28

Hepatic Lipidosis: Diagnosis
- ultrasound

Answer 28

• Large hyperechoic liver
• Signs of underlying disease

Question 29

Hepatic Lipidosis: Diagnosis usually based on?

Answer 29

• Diagnosis usually based on history, clinical presentation, labwork and imaging
  > Not specific

Question 30

Hepatic Lipidosis: how to make a definitive diagnosis

Answer 30

Definitive diagnosis can be made:
* Liver cytology yielding lipid (can mask other disorders)
> Ill cats tend to accumulate lipid in liver
* Biopsy
> Often not ideal candidates for anaesthesia, biopsy

Question 31

Hepatic Lipidosis: Treatment

Answer 31

• Supportive care
  > IV fluids and electrolyte correction
• Nutritional support is cornerstone of treatment
  > Often nasogastric or nasoesophageal tube initially
  > Esophagostomy tube under anesthesia when more stable
  > Ideal diet high in protein, moderate in lipid, lower carbohydrate
  > Small frequent meals, gradual increase to meet RER
• Vitamin K for potential coagulopathy
• Consider antioxidant & nutraceuticals
  > SAMe, l-carnitine, Vitamin B12, taurine
  > Caution if too many oral medications
• Treatment of underlying disorders
  > E.g., analgesia with opioids if pancreatitis

Question 32

Hepatic Lipidosis: Prognosis

Answer 32

• Very good prognosis with nutritional support and absence of serious underlying disease

Question 33

Elevated neutrophils, pyrexia, liver enzyme activity
- differentials?

Answer 33

• Neutrophilic cholangitis
• Pancreatitis

Question 34

Elevated ALP (ALP&raquo_space; GGT) differentials?

Answer 34

• Hepatic lipidosis
• Cholangitis
• Pancreatitis