Smallies 7 - Liver Flashcards
What is required in the dietary treatment for Copper Storage Disease?
Feed a low copper diet with increased dietary zinc
Avoid tap water in soft water areas with Cu pipes
Avoid high Cu treats e.g. shellfish, liver, kidney, cereals, chocolate
What is included in the general supportive care for Copper Storage Disease?
As for chronic hepatitis
Antioxidants such as SAM-e and Vitamin E
Ursodeoxycholic acid
What is the use of copper chelating agents in the treatment for Copper Storage Disease?
Bind free extracellular Cu which is then excreted by kidneys e.g. d-Penicillamine
Use to ‘de-copper’ the liver when biopsy proven or true copper storage breed
What is the use of zinc salts in the treatment for Copper Storage Disease?
Reduce absorption of Cu from the GIT
Use to prevent Cu accumulation
Don’t use with copper chelating agents
When is medical management important for congenital portosystemic shunts?
When stabilising a patient for surgical management
When surgery is not possible
When surgery has not been fully successful
List examples of canine primary hepatic neoplasia
Hepatocellular carcinoma Hepatocellular adenoma Haemangiosarcoma (primary/secondary) Biliary carcinoma Biliary adenoma Lymphoma Neuroendocrine tumours Leiomyosarcoma
What are clinical signs of hepatic neoplasia in dogs?
Often non-specific clinical signs e.g. lethargy, poor appetite
Signs may be associated with a complication e.g. abdominal bleed?
Palpable mass may be only sign
Signs as for chronic chronic hepatitis
What is the treatment for hepatic neoplasia in dogs?
Surgery is treatment of choice but assess for metastatic disease before major interventions by doing thoracic radiographs R and L lateral +/- DV
Chemotherapy only effective for lymphoma (but all chemotherapy drugs are metabolised by the liver so may see more adverse effects – control doses carefully)
What are possible causes of neutrophilic cholangitis in dogs?
Ascending infection or haematogenous spread
Streps, E coli, Klebsiella, Proteus
What are clinical signs of neutrophilic cholangitis in dogs?
Clinical signs are variable but can include lethargy, pyrexia, vomiting and icterus
What is seen on clinical pathology with neutrophilic cholangitis in dogs?
Variable liver enzyme elevations, increased bilirubin
Neutrophilia with/without left shift
What is required to make a diagnosis of neutrophilic cholangitis in dogs?
Diagnosis requires bile centesis +/- liver biopsy
What is the treatment for neutrophilic cholangitis in dogs?
Antibiotic treatment based on culture results
Treat for 8 weeks minimum
What are possible causes of extrahepatic bile duct obstruction in dogs?
Pancreatitis or pancreatic tumour Bile duct tumour Duodenal FB or mass GB mucocoele Cholelithiasis Local trauma, inflammation
What are clinical signs of extrahepatic bile duct obstruction in dogs?
Signs very often due to underlying reason for obstruction
Very variable, non-specific in early stages
Depends on whether partial or complete obstruction
Pointing to post-hepatic jaundice
What is needed for the diagnosis of extrahepatic bile duct obstruction in dogs?
Clinical pathology - ALP, bilirubin usually very high
Ultrasound to determine if cause can be seen
What are the causes of bile duct rupture from canine biliary tract disease?
Usually same causes as extra hepatic bile duct obstruction Pancreatitis or pancreatic tumour Bile duct tumour Duodenal FB or mass GB mucocoele Cholelithiasis Local trauma, inflammation
What are the consequences if bile duct rupture?
Bile peritonitis leading to abdominal effusion
What are the clinical signs of bile duct rupture?
Profound jaundice common
Abdominal pain +/- distention
What is the treatment of bile duct rupture?
Surgery to manage underlying cause
Cholecystectomy - histopathology and culture of gall bladder wall
Why should hypertonic saline be avoided in dehydrated patients?
It will cause cellular dehydration and intensify the hypovolaemia by intensifying diuresis before plasma volume expansion has been achieved
Why would you perform a liver biopsy?
Part of routine screen Mass Generalised hepatopathy Hepatitis Jaundice
What are portosystemic shunts?
Portosystemic shunts are an anomalous connection between the portal and systemic venous systems.
What is the ductus venosus?
Normal bypass of the liver in utero, this then becomes a ligament once born)
What are examples of abnormal liver bypasses?
Persistent (patent) ductus venosus
Intrahepatic e.g. persistent ductus venosus. Normally it should close and become a ligamentum within the first 24-48hrs
Extrahepatic
What is more common in large and small breeds of dog - intra or extrahepatic shunts?
In general, large breed dogs more commonly get intrahepatic shunts and small breed dogs more commonly get extrahepatic shunts
What is portal vein hypoplasia - microvascular dysplasia?
Communication between portal and systemic circulation at a microvascular level. Get abnormal shunting of portal blood at a microscopic level within the liver itself
What breeds are predisposed to portal vein hypoplasia - microvascular dysplasia?
Cairn and Yorkshire Terriers
What are common clinical signs of PSS?
Most commonly neurologic (hepatic encephalopathy) - Lethargy, ataxia, obtundation, pacing, circling, blindness, seizures, coma
What are GIT signs of PSS?
Vague
Vomiting, diarrhoea, anorexia, pica, melaena, haematemesis
What are urinary signs of PSS?
Haematuria, stranguria, pollakiuria, urethral obstruction (from crystals of ammonium biurate)
How are PSS medically managed?
With lactulose
Why is lactulose used in the treatment of PSS?
Lactulose helps to bind ammonia so prevent it being absorbed into the bloodstream. It also causes the patient to go to the toilet more regularly which helps to remove the bacterial load.
What is the surgical treatment of PSS?
Surgical ligation
Ameroid ring
Cellophae banding
Percutaneous transvenous coil embolism
How does surgical ligation treat PSS?
If you completely occlude the vessel you may cause portal hypertension, it is common to partially close the vessel which will allow full closure over the next few weeks
What suture material should you use for ligation of PSS?
Polyprolene (non-reactive)
Silk (reactive)
What are the two types of surgical ligation of PSS?
Complete attenuation
Partial attenuation
What is an ameroid ring and how can it treat a PSS?
Ring of casein surrounded by stainless steel
Hygroscopic substance that swells after absorbing fluid
Incites a fibrous tissue reaction
What is cellphane banding and how can it treat a PSS?
Clear non-medical grade cellophane put around the shunt
Fibrous tissue reaction leading to gradual occlusion – foreign body reaction around the vessel and within the vessel wall
When are percutaneous transvenous coil embolisms used to treat PSS?
USed for intrahepatic shunts
What is a percutaneous transvenous coil embolisation and how does it treat a PSS?
Caval stent placed via jugular vein
Insert embolisation coils inserted through a large vascular catheter
Self extends which stays in place forever
What are PSS surgical complications?
Hypoglycaemia
Portal hypertension Seizures
How can post PSS op seizures be treated?
Propofol infusion - CRI for several days
List causes of extra hepatic biliary tract obstruction
Pancreatitis Gallbladder mucocoele Cholelithiasis Inspissated bile Neoplasia Parasites Duodenal foreign body Malformations Fibrosis Stricture formation
What is the most common cause of extra hepatic biliary tract obstruction?
Pancreatitis
How can pancreatitis cause extra hepatic biliary tract obstruction?
Drainage of pancreatic enzymes usually through major duodenal papilla, common bile duct enters at same site - obstruction/inflammation of that site can mean pancreatitis, which may also be causing obstruction of the common bile duct at this site
What are indications of cholecystectomy?
Ruptured gallbladder Primary neoplasia of the gallbladder Cholecystitis that is unresponsive to medical management Gallbladder mucocoele Cholelithiasis
What is gall bladder mucocoele associated with?
Stasis of the gall bladder material
Why do you get gall bladder mucocoele with stasis of the gall bladder?
The bile has remained static in the gall bladder, so the water is drawn out leaving a sludgy material behind
What breeds are most likely to get gall bladder mucocoele?
Seen more in Terrier breeds especially the Border Terrier
How do you diagnose gall bladder mucocoele?
Will detect an enlarged gall bladder on imaging
What is the treatment for gall bladder mucocoele?
Cholecystectomy is the treatment of choice
What are the indications for a permenant biliary bypass?
Any underlying disease that has led to permanent and complete obstruction of the bile duct, major duodenal papilla or proximal duodenum
Where resection of the proximal duodenum including the bile duct is required
What are common causes for a permanent biliary bypass?
Cholelithiasis
Neoplasia of bile duct, pancreas or duodenum
Pancreatitis (rarely)
What is a Cholecystoduodenostomy?
permanent opening into duodenum
What is a cholecystojejunostomy?
permanent opening into the jejunum
What is a choledochoenterostomy?
connection of bile duct into small bowel
What are the indications for a temporary biliary bypass?
Pancreatitis
Decompress EHBDO to stabilise patients before definitive surgery
When is pancreatic surgery indicated?
As part of a routine organ biopsy screen for: o Mass o Pancreatitis o Jaundice o Cholangiohepatitis
What does a primary islet cell tumour produce?
Insulin
What are the signs of a primary islet cell tumour?
hypoglycaemia
lethary
exercise intolerance
