Hepatobiliary Disease Flashcards
Ascites
abnormal accumulationof serous fluid within the peritoneal cavity. the fluid is typically of moderate to low protein and cellularity (pure or modified transudate), and is a consequence of serious hepatic disease (that causes portal hypertension) or RHF
Cirrhosis
Progressive disease of the liver characterized by diffuse and progressive loss of hepatocytes and their replacement with fibrous tissue. Frequently results in portal hypertension, multiple acquired PSS, ascites, and ultimately liver failure
Icterus (Jaundice)
Yellow discoloration of serum/plasma and tissue (skin, sclera, mucous membranes), and excretions due to hyperbilirubinemia. Tissue discoloration is commonly seen once serum bilirubin is >2.0 mg/dl
Hepatic encephalopathy
a potentially reversible neurologic syndrome (behavioral abnormalities, mental dullness, ataxia, circling, head pressing, ptyalism(cats), cortical blindness, seizures, coma) that occurs in animals with liver failure
Acholic feces
grey-white colored feces resulting from an absence of bilirubin pigments (stercobilin) in the GI tract due to complete bile duct obstruction. This phenomenon is rare because very small amounts of bilirubin impart color to feces
Screening test for liver disease
serum biochemistry profile
Liver function test
pre & post-prandial serum bile acids
What are the most common CBC changes with hepatobiliary disease?
- Microcytosis (low MCV): common in dogs with congenital PSS
- RBC membrane abnormalities (acanthocytes, leptocytes, target cells): seen with hepatobiliary disorders due to alterations in lipoprotein metabolism
- Inflammatory leukogram: consider inflammatory hepatic disease
- Anemia: helps in your diagnostic approach to icterus (rule out hemolysis)
What are some of the more common causes of reactive hepatopathy?
- endocrinopathies
- hyperadrenocorticism, DM, hyperthyroidism
- pancreatitis
- GI disease
Three key parts of history to focus on when hepatobiliary disease is suspect and examples of specific concerns
- Diet
- new bag or recalled dog food: aflatoxin
- artificially sweetened human food: xylitol
- dietary indiscretion: pancreatitis
- Environment
- access to water: Lepto, blue-green algae
- mushroom ingestion: amanita
- ornamental plant: cycad
- Drugs
- NSAIDs
- Steroids(induction of ALP)
- Anticonvulsants(phenobarb-dogs, valium-cats)
- Antibiotics (Sulfas, tetracyclines, ketaconazole)
ALP > ALT sugggests damage to what?
biliary system (ALP is expressed in the endothelial cells that line the biliary tree)
ALT>ALP suggests what type of damage?
hepatocellular
What are the major causes of increased serum ALP?
- cholestatic liver disease
- rapid growth of bone in young animal
- drug induced (steroids, phenobarbital)
- NOT in cats
How are ALP and GGT different in cats vs. dogs?
ALP and GGT in the cat have lower liver concentrations and shorter half lives
this means ANY elevation in serum ALP & GGT is considered significant in cats
What are ddx for increased bilirubin?
- hepatic & post hepatic causes of cholestasis
- sepsis
Cholesterol decreases with _________, or may increase with ________
decreased cholesterol if liver function deteriorates
increased cholesterol in the case of cholestasis
What are the four parameters that decrease with decreased liver function?
- cholesterol
- BUN
- albumin
- glucose
USG with liver fnction is commonly _______
dilute
Some bilirubinuria may occur in _________
dogs (esp. males)
Bilirubinuria is always concerning in _____
cats
Common UA finding with congenital PSS
ammonium biurate crystals
When to collect blood for SBA test
after a 12h fast and 2h following a small meal
Differentials for increased SBA (from clin path)
Decreased clearance from portal blood
- PSS
- loss of functional mass
Decreased excretion into bile
- cholestasis (hepatic or post-hepatic
Physiologic
- gallbladder contraction may elevate fasting bile acids
When is SBA not indicated?
if patient is icteric and cannot differentiate hepatic from post-hepatic causes
Breeds predisposed to copper storage hepatopathy
- Bedlington terrier
- Doberman pinscher
- Dalmation
- Labrador retriever
- West highlan white terrier
- Skye terrier
- Cocker spaniel
Breeds predisposed to biliary disease
- Shetland sheepdogs
- Cocker spaniels
- Chihuahua
Breeds predisposed to liver vascular anomalies (PSS, portal v. hypoplasia)
- yorkie
- maltese
- lhasa apso
- cairn
- schnauzer
- pug
- shih tzu
List some secondary hepatopathies and the associated serum chem findings that may tip you off to them
DM-hyperglycemia
Hypotheyroidism-hypercholesterolemia
Hyperlipidemia-hypertriglyceridemia
Lymphoma-hypercalcemia
Pancreatitis-elevated amylase/lipase
PLE-panhypoproteinemia
What should you do if serum chem is normal but patient has signs of encephalopathy?
Liver function tests
What are two instances where liver failure may be present & patient has signs of encephalopathy, but the serum chem is normal?
- congenital PSS
- late-stage fibrosis
Pre-hepatic hyperbilirubinemia is due to _________
increased hemolysis of RBCs
Ddx for hepatic causes of hyperbilirubinemia
- cholangitis
-
diffuse hepatocellular disease
- hepatic lipidosis
- infectious (lepto) or idiopathic cholangiohepatitis
- neoplastic (e.g. lymphoma)
- drug or toxin - induced injury
Differentials for post-hepatic hyperbilirubinemia
- pancreatitis
- cholecystitis/mucocele
- liver flukes, choleliths
- pancreatic or biliary neoplasia
3 ddx for increased cholesterol besides liver
- hyperlipidemia disorders
- hypothyroidism
- nephrotic syndrome
Ddx for decreased cholesterol besides decreased liver function
PLE
Differentials for decreased glucose besides decreased liver function
- insulinoma
- Addison’s disease
- Toy breed glycogen storage defect
- sepsis
What are some differentials for decreased albumin besides decreased liver function?
- PLN
- PLE
- vasculitis
- blood loss
Feline-tests for dx reactive hepatopathy
- fPLE/abdominal ultrasound (pancreatitis)
- T4 (hyperthyroid)
- fecal sedimentation (liver flukes; SE US)
- Infectious dz titers/PCR (Cytaux, Toxo, Histo, etc)
Canine-tests for dx of reactive hepatopathy
- cPLI/abdominal ultrasound (pancreatitis)
- ACTH stim/LDDST (Cushing’s)
- infectious disease titers/PCR (Lepto)
SBA and secondary hepatopathies?
most secondary hepatopathies will have normal SBA
Liver synthesizes what clotting factors?
II, VII, IX, X
(vitamin K dependent)
Liver size is best evaluated with ______
abdominal rads
Ddx for hepatomegaly
Infiltrative disease
- round cell neoplasia
- extramedullary hematopoeisis
- acute inflammation
Storage (vacuolar) disorder
- lipid
- glycogen
- congenital
- amyloid
Congestion
- RHF
What should you always do if you have an abdominal effusion?
fluid analysis & cytology
What are some potential gallbladder/biliary problems?
sludge, edema, mucoceole, calcification, choleliths, neoplasia
What are some vascular problems with the liver?
- intra-hepatic shunt
- congenital single PSS
- multiple acquired extrahepatic shunts
- portal vein hypoplasia
- portal hypertension
- arteriovenous fistula
Diagnostic procedure for gallbladder/biliary issues
percutaneous ultrasound - guided cholecystocentesis
What type of biopsy is needed for copper quantification?
laparoscopic/surgical biopsy
Potential causes of canine chronic hepatitis
- familial (includes copper storage disorders)
- drug associated, aflatoxins
- infectious
- chronic bacterial cholangitis, lepto, infectious canine hepatitis
- idiopathic/immune-mediated
What does D-penicillamine do?
chelates copper
Dietary considerations for dog with chronic hepatitis
- high quality protein (only restrict if signs of hepatic encephalopathy)
- Copper restricted diet if excess copper identified
- anti-oxidant rich
- highly palatable
What are the signs associated with hepatic encephalopathy?
Behavioral
- personality change (aggression)
- staring, pacing
- psychogenic PU/PD
Neurologic
- cortical signs (head-pressing, seizures, coma)
- vestibular (staggering, ataxia, circling)
Gastrointestinal
- vomiting (+/- hematemesis; e.g. if GI ulcers)
- hypersalivation (esp. cats)
- diarrhea (+/- melena)
- inappetence/anorexia
Liver fluke-scientific name
Platynosomum concinnum
Very abnormal coag profiles are most likely in what cases?
- acute liver failure
- complete bile duct obstruction
- DIC
Contrast radiographs aren’t usually used to evaluate hepatobiliary disease with the exception of _______________
portosystemic shunts, in which case portal venography is sometimes used to confirm presence or location of a shunt vessel.
What is the use of splenoportal scintigraphy?
to look for portosystemic shunting when it is suspected but cannot be confirmed with ultrasound
Liver biopsy-why and when?
- determine a diagnosis and prognosis of a suspected hepatobiliary disorder (e.g. unknown cause of hepatomegaly, persistently elevated liver enzymes, abnormal liver function test, or hepatic icterus)
- stage neoplastic disease
- determine hepatic involvement of a systemic disease
- assess response of hepatobiliary disease to therapy
S-adenosylmethionine (SAMe) mechanism of action
provides methionine in support of glutathione synthesis->defense against oxidative injury
Considerations when giving SAMe
- give on empty stomach
- be particular about the source/ Denosyl-SD4 has proven bioavailability
Treatment for amanita mushroom
Silibinin/Silymarin (Milk thistle)
Potential side effects of colchicince
- hemorrhagic gastroenteritis
- bone marrow suppression
- renal injury
- peripheral neuropathies
- potential teratogenic and abortifacient effects-warn owners
Colchicine can be used concurrently with what drugs?
- UDCA
- glucocorticoids
- antioxidants
Colchicine is NOT recommended to use concurrently with what drugs?
- azathioprine
- methotrexate
- chlorambucil
Most important non-inflammatory liver disease in cats
hepatic lipidosis
Two type of inflammatory liver diseases seen in cats. which is most common?
- neutrophilic cholangitis (most common)
- lymphocytic cholangitis
What breed of cat tends to get lymphocytic cholangitis more?
persians
____% of cats with cholangitis also have pancreatitis
50%
___% of cats with cholangitis also have IBD
83%
Histologic findings-canine chronic hepatitis
- mixed inflammation
- hepatocyte apoptosis/necrosis
- fibrosis
- biliary hyperplasia
- nodular regeneration
Diagnostic test for hepatic icterus
liver biopsy
Diagnostic test for posthepatic icterus
abdominal ultrasound
Diagnostic test for prehepatic icterus
PVC and TS
