hepatobiliary 3: more cholangitis, hepatic lipidosis, etc. Flashcards
Lymphocytic Cholangitis cause
- Cause unknown
- Immune mediated?
- Transient infection causing immune stimulation and hepatic inflammation?
Lymphocytic Cholangitis history
Often lengthy history of intermittent clinical signs, slowly progressive
Lymphocytic Cholangitis signalment
– any age, breed, sex
Lymphocytic Cholangitis Clinical signs
- 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
Lymphocytic Cholangitis: Presentation on PE
- Poor body condition
- Hepatomegaly
- Ascites in 1/3 of cats (high protein fluid)
- Possible signs of hepatic encephalopathy
- Pyrexia not common
Lymphocytic Cholangitis: CBC
CBC generally normal
* Can see mild non regenerative anemia
Lymphocytic Cholangitis: biochem? vs neutrophilic cholangitis?
- 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
Lymphocytic Cholangitis: abdominal fluid
- Can be moderate to marked
- High protein content, small lymphocytes/inflammation
Aside from lymphocytic cholangitis, What’s another differential for high globulins, low albumin, abdominal effusion (high protein)?
- Feline infectious peritonitis (FIP)
Lymphocytic Cholangitis: radiographs
- Hepatomegaly, ascites evident on
radiographs
lymphocytic cholangitis ultrasound findings
possible findings:
* Normal to coarse hepatic echotexture
* Abdominal lymphadenomegaly
* Ascites
* Gall bladder and biliary tracts: normal or dilated tracts, sludge GB
* Concurrent pancreatitis / enteropathy
Lymphocytic Cholangitis Clinical features can overlap with:
FIP, hepatic lymphoma, neutrophilic cholangitis
lymphocytic cholangitis Definitive diagnosis requires
Definitive diagnosis requires biopsy
* Portal lymphocytic infiltration
* Ductopenia
* Peribiliary fibrosis
Lymphocytic Cholangitis: Treatment
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
Lymphocytic Cholangitis: Prognosis
- 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
Hepatic Lipidosis predisposing factors
- Negative energy balance usually the predisposing factor
- Clinically, 2-14 days of anorexia precedes HL
- Obesity can predispose
primary vs secondary hepatic lipidosis - what are they and which is most common?
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
Hepatic Lipidosis: Pathophysiology, definition
- 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
Common underlying or concurrent diseases for hepatic lipidosis
> Pancreatitis, diabetes mellitus, primary hepatobiliary disease, IBD, neoplasia
Hepatic Lipidosis: signalment and risk factors
- Any age, breed; often middle-aged to older
- Risk factors: obesity, stressful event/illness
Hepatic Lipidosis Clinical signs & examination
- 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
Hepatic Lipidosis: Diagnosis
- enzymes
- 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)
Hepatic Lipidosis: Diagnosis
- electrolytes
- Electrolyte derangements (low K, P, Mg)
Hepatic Lipidosis: Diagnosis
- CBC
- CBC: anemia common
Hepatic Lipidosis: Diagnosis
- coagulopathy?
common
Laboratory abnormalities for hepatic lipidosis can reflect what?
can reflect underlying disease
* E.g., elevated lipase with pancreatitis
Hepatic Lipidosis: Diagnosis
- radiographs
Radiographs can show hepatomegaly
Hepatic Lipidosis: Diagnosis
- ultrasound
- Large hyperechoic liver
- Signs of underlying disease
Hepatic Lipidosis: Diagnosis usually based on?
- Diagnosis usually based on history, clinical presentation, labwork and imaging
> Not specific
Hepatic Lipidosis: how to make a definitive diagnosis
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
Hepatic Lipidosis: Treatment
- 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
Hepatic Lipidosis: Prognosis
- Very good prognosis with nutritional support and absence of serious underlying disease
Elevated neutrophils, pyrexia, liver enzyme activity
- differentials?
- Neutrophilic cholangitis
- Pancreatitis
Elevated ALP (ALP»_space; GGT) differentials?
- Hepatic lipidosis
- Cholangitis
- Pancreatitis
