Lecture 14 2/12/25 Flashcards
What is feline hepatic lipidosis?
metabolic syndrome characterized by hepatic lipid accumulation
What is the etiology of feline hepatic lipidosis?
-consequence of negative energy balance in over-conditioned cats
-hyporexia/anorexia is usually secondary to another disease; GI dz, pancreatitis, cholangitis
-can be idiopathic
What is the pathophysiology of feline hepatic lipidosis?
-negative energy balance leads to peripheral fat mobilization
-delivery to liver exceeding mitochondrial beta-oxidation leads to triglyceride accumulation in the hepatocytes
-cytosolic distension with triglycerides leads to intracellular dysfunction and extracellular compression of canaliculi
What is the clinical presentation of feline hepatic lipidosis?
-middle-aged cats
-often over-conditioned
-history of hyporexia/anorexia, lethargy, weight loss, vomiting, diarrhea
-dehydration, hepatomegaly, and icterus seen on PE
What are the findings on biochemical testing in cats with hepatic lipidosis?
-marked increase in ALP that is almost always greater than the increase in GGT
-hyperbilirubinemia
-increased ALT and AST
-electrolyte derangements
-mild hyperglycemia
-increased beta-hydroxybutyrate due to ketogenesis in the liver
-underlying disease can cause increased GGT, hypoalbuminemia, and hyperglobulinemia
What are the findings on CBC in cats with hepatic lipidosis?
-mild nonregenerative anemia
-poikilocytosis (abnormal shape)
-heinz bodies
-possibility of mature neutrophilic leukocytosis (underlying dz)
What are the findings on UA in cats with hepatic lipidosis?
lipid droplets
What are the findings on coagulation testing in cats with hepatic lipidosis?
often abnormal PT and PTT
What are the findings on abdominal ultrasound in cats with hepatic lipidosis?
-diffusely hyperechoic liver
-hepatomegaly
How is hepatic lipidosis diagnosed?
-consistent signs
-bloodwork changes
-hepatic cytology
-hepatic biopsy ONLY if suspicious of another hepatobiliary dz
What are the differential diagnoses for hepatic lipidosis?
-cholangitis
-extrahepatic bile duct obstruction
-hepatocellular neoplasia
What are the goals of hepatic lipidosis management?
-correct dehydration
-correct electrolyte changes
-reverse the negative energy balance
What are the characteristics of fluid therapy for hepatic lipidosis patients?
-use isotonic crystalloids without lactate buffer
-replace volume based on lean body mass
-supplement with potassium, phosphorus, and B-vitamin
-avoid dextrose supplementation
What are the characteristics of nutritional support for hepatic lipidosis patients?
-enteral feeding starts once hydration and electrolytes are normal
-can use nasoesophageal or nasogastric feeding tubes
-feed a protein enriched diet
-begin feeding at 1/4 or 1/3 RER and gradually increase over 2 to 3 days
-can do CRI or 4 to 6 small bolus feedings throughout day
What are the characteristics of esophageal tubes for hepatic lipidosis patients?
-can be placed once patient is stable and has received 2 to 3 doses of vitamin K1
-can be used to provide medication and allow for increased food options
-can be managed by owners
-antiemetics used to prevent vomiting/expulsion of the tube
What other supportive care can be done in hepatic lipidosis patients?
-vitamin K1 supplementation
-antioxidants
-metabolic supplements
What is the prognosis for hepatic lipidosis?
-good if diagnosed early, treated proactively, and underlying problem is identified and addressed
-good prognostic indicators include reduction in beta-hydroxybutyrate during hospitalization and reduction in bilirubin within 1 to 2 weeks of therapy
-poor prognostic indicators include hypotension, effusions, and progressive hypoalbuminemia and hyperbilirubinemia
What are the characteristics of feline cholangitis?
-inflammatory process targeting the bile ducts/ductules expanding within the portal tract
-classification is based on the predominant cellular infiltrate and duration of illness
-common comorbidities include pancreatitis and IBD
What are the 3 main subtypes of feline cholangitis?
-neutrophilic (acute and chronic)
-lymphocytic
-chronic (fluke associated)
What is the etiology of acute and chronic neutrophilic cholangitis?
-most commonly bacterial infection
-rarely protozoal infection
What is the etiology of lymphocytic cholangitis?
unknown
Which fluke is most commonly the cause of chronic cholangitis?
Platynosomum concinnum
What is the pathophysiology of neutrophilic and chronic/fluke cholangitis?
-infectious organisms cause direct injury to biliary epithelium
-secondary induction of innate and adaptive immune responses targeted at clearing dead cells and infection leads to maintained inflammation and tissue damage
-extrahepatic bile duct obstruction can occur due to fluke obstruction, thickened bile, or cholelithiasis
What is the pathophysiology of lymphocytic cholangitis?
-immune-mediated disease targeting the biliary epithelium leads to periductal and intraductal lymphocyte infiltration and myofibroblast activation
-cell infiltration/activation leads to extracellular matrix deposition and potentially bile duct destruction
What is the clinical presentation of acute neutrophilic cholangitis?
-young cats
-short duration of illness
-signs including abdominal pain, dehydration, fever, GI signs, and icterus
What is the clinical presentation of chronic neutrophilic cholangitis?
-cats of any age
-waxing and waning signs
What is the clinical presentation of lymphocytic cholangitis?
-middle-aged to older cats
-no breed or gender predisposition
-signs including intermittent vomiting, diarrhea, anorexia, and icterus
What is the clinical presentation of fluke-associated cholangitis?
-free-roaming cats in tropical/subtropical regions
-acute phase patients can be asymptomatic or present with anorexia and lethargy
-chronic infection presents with cyclic abdominal pain, chronic mucoid diarrhea, and icterus
-high fluke burden can lead to severe inflammation, extrahepatic bile duct obstruction, or death
What are the differential diagnoses for neutrophilic and fluke-associated cholangitis?
-hepatic abscess
-pancreatitis
-extrahepatic bile duct obstruction
-stricture
-neoplasia
What are the differential diagnoses for lymphocytic cholangitis?
-hepatobiliary neoplasia
-chronic pancreatitis
-reactive hepatopathy
-FIP
What are the clin path findings in acute neutrophilic cholangitis?
-neutrophilia with left shift and toxic changes
-hyperbilirubinemia
-increases in GGT and ALP; GGT > ALP
-marked increase in ALP if concurrent with lipidosis
-moderate to severe ALT and AST increases
-hyperglobulinemia
-electrolyte derangements
-coagulopathy
-pre-renal and/or renal azotemia
What are the clin path findings in lymphocytic cholangitis?
-regenerative/nonregenerative anemia with poikilocytosis
-moderate to severe increase in ALT and AST
-relatively higher GGT/ALP ratios
-mild hyperglobulinemia
-hyperbilirubinemia
What are the clin path findings in fluke-associated cholangitis?
-mild non-regenerative anemia
-hypereosinophilia
-lymphocytosis
-hyperbilirubinemia
-increased ALT and AST
How is cholangitis diagnosed?
-fecal float (fluke-associated)
-abdominal ultrasound
-cholecystocentesis and bile analysis
-liver FNA
-histology (definitive)
What are the management steps for neutrophilic cholangitis?
-correction of dehydration and electrolyte abnormalities
-vitamin K1 prior to invasive procedures
-antioxidants
-nutritional support
-antibiotic therapy
What are the management steps for lymphocytic cholangitis?
-immunosuppression with prednisolone
-ursodeoxycholic acid in cats without ductopenia
-antioxidants
-modulation of gut flora
-close monitoring of ductopenic cats
What are the management steps for fluke-associated cholangitis?
-praziquantel
-repeat fecals to assure clearance
What is the prognosis for cholangitis?
-often have comorbidities; should be identified and treated appropriately
-good prognosis for fluke-associated and neutrophilic cholangitis if identified early
-lymphocytic cholangitis requires chronic therapy and monitoring; remission possible before inevitable relapse/progression to lymphoma
-ductopenic cats have poorer prognosis in lymphocytic cholangitis
