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CANINE BILIARY DISEASEGallbladder mucocoeles, Cholangitis, Extrahepatic bile duct obstruction
Dr Dave Collins, BVSc FANZCVS
dcollins@sashvets.com
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Biliary disease
Clinical Signs: abdominal pain, jaundice, vomiting, lethargy, +/-pyrexia
Lab: elevated liver enzymes, bilirubin, +ve snap cPL, neutrophilia
DDx: GI, Pancreatitis
Hepatitis/cholangiohepatitis: infectious, drugs, toxic
Cholangitis
Pancreatitis – cyst, abscess, neoplasia
Biliary disease: cholangitis, cholecystitis, biliary mucocoele, cholelithiasis, neoplasia, EHBDO
Ultrasound findings
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Biliary tree
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Gallbladder Mucocoeles
Progressive accumulation of tenacious mucin-laden bile
May extend into cystic, hepatic & common bile ducts variable EHBDO
Consequences: GB ischaemic necrosis, bile peritonitis +/- opportunistic infection
IBD much more prevalent in dogs with GB mucocoele
Clinical Signs: vomiting, inappetance, lethargy, PU/PD, diarrhoea; severity of signs relating to degree of EHBDO, rupture or infection
Physical examination: Abdominal pain, icterus, pyrexia
Laboratory Findings: ALP elevation, hyperbilirubinaemia 60%, mature neutrophilia, monocytosis
Diagnosis: ultrasonographic appearance, clinical signs, clin path
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Gallbladder Mucocoeles – Risk factors
Breed :Shetland Sheepdog (ABCB4 mutation) , mixed, Bichon, poodles, WHWT, Dachsund, GSD, Cocker Spaniels, Miniature Schnauzers
Age: average 11 years, no gender predisposition
Endocrinopathies: hyperA, hypoT, diabetes mellitus
Pancreatitis
Gallbladder dysmotility
High fat diet
Protein losing nephropathy
Gallbladder neoplasia
Hyperlipidaemia
Glucocorticoid treatment in predisposed dogs
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Gallbladder Mucocoeles
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Gallbladder Mucocoeles
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Gallbladder Mucocoele
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Gallbladder rupture Bile peritonitis
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Canine Bacterial Cholangitis
Cholangitis: inflammation of the intrahepatic bile ducts and ductulesrestricted to the portal areas
Bacterial cholangitis rarely reported in the dog, cholecystitis also uncommon
Is canine and feline bile sterile in the absence of biliary tree pathology??
Potential bacterial invasion via: ascension from duodenum; haematogenousvia hepatic portal venous blood
Biliary defense mechanisms:
mechanical (biliary stasis and increased biliary pressure predispose an animal to biliary infection)
immunological (enteric bacteria normally gain entry to portal circulation and are extracted by hepatic Kupffer cells)
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Canine Bacterial Cholangitis
Limited reports in literature, few single case reports, case series of 4 (4/95 cases with chronic hepatopathy Bristol)
Inclusion criteria: positive bile culture, concurrent liver histopathology demonstrating periportal neutrophilic infiltrate
May occur much more frequently than reported
190 dogs Madison-Wisconsin: 28% biliary cultures, 5% hepatic cultures positive
Positive bile cultures may occur in health or may be secondary to other chronic hepatopathy
Aetiopathogenesis: ascending gut infection or translocation from portal circulation
May be concurrent cholangitis in cases of cholecystitis or biliary mucocoele
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Canine Bacterial Cholangitis - Clinical
Older animals (8-10), no sex predilection
Vomiting, icterus, inappetance, lethargy, diarrrhoea +/- pyrexia
Marked liver enzyme elevation and hyperbilirubinaemia in most
Inflammatory leukogram with mature neutrophilia typical
Ultrasonography: thickening, increased echogenicity of gallbladder wall +/-diffuse changes in hepatic parenchyma; (may be concurrent choleliths, mucocoeles; concurrent cholecystitis common)
Diagnosis: neutrophilic infiltrate in periportal areas, positive hepatobiliarybacteriological culture (anaerobic & aerobic), bile more sensitive
4-6 weeks antimicrobials based on C & S, repeat culture post therapy
+/- UDCA, cholecystectomy
Good prognosis
Other Differentials
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Emphysematous cholecystitis
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Emphysematous cholecystitis
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Cholelith
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13 FN Chihuahua cross
Pyrexia 40.4, abdominal pain
Blirubin 128 umol/L (0-7); ALP 5546 IU/L (1-150)
AST 715 IU/L (18-80); ALT 1601 IU/L (16-90) Cholesterol 14.3 mmol/L (3.5-9.0);
Neutrophilia 18x10^9/L (3.5-12); Canine Pancreas Specific Lipase 627 ug/L (<200) Elevated APTT 168 (72-102) with normal PT.
IVF, ampicillin, enrofloxacin, metronidazole, methadone, vitamin K
24 hours APTT 99, 48 hours (pre-surgery) bilirubin 60 umol/L (0-7)
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Gallbladder
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CBD
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13 FN Chihuahua cross
Day 2: ex-lap, flush bile duct, cholecystectomy
72 hours ALT 108 ALP 2992 bilirubin 36
Discharged 6 days after admission, appetite starting by day 5
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13 FN Chihuahua cross
HISTOPATHOLOGY REPORT
Moderate to marked chronic-active cholecystitis (frequently suppurative and with presumed ischemic necrosis of mucosa and marked fibroplasia)
Moderate to marked chronic-active (frequently suppurative) cholangiohepatitis with marked cholestasis.
MICROBIOLOGY REPORT
Liver and bile
CULTURE (Blood agar, aerobic, 37C ; cooked meat medium, 37C)
No bacteria isolated aerobically.
Clostridium perfringens was isolated in cooked meat medium from both the liver biopsy and the bile (only very light growth from the bile).
Treatment: 4 weeks of amoxiclav and enrofloxacin
Antimicrobials
Enterococcus*
Strep* Staph E Coli* Pasteurella Enterobacter
Pseudom/Klebsiella
Clostridia sp.*
Bacteroides*
Penicillin - +++ - to + - to ++ +++ - - +++ -
Ampicillin - +++ - to + - to ++ +++ - - ++ -
Amoxicillin/clavulunate
+ to
++++++ + to
+++- to ++ +++ - -/+ ++ +++
Ticarcillin/clavulanate
++ +++ - to
+++- to ++ +++ +++ + to +++ +++ +++
Enrofloxacin - to + - to + - to + +++ +++ +++ ++/+++ - to + -
Cefazolin - +++ - to + ++ +++ - -/+++ - to +++ -
Metronidazole - - - - - - - +++ +++
Clindamycin - ++ - to
+++- - - - +++ +/-
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Supportive medications
Vitamin K 0.5 -1.5mg/kg SC q12h x 3
Vitamin E 10-15U/kg PO q24h (Value Plus Vitamin E Equine powder 52U/g)
UDCA 7.5mg/kg PO q12h with food
SAMe 20-40mg/kg PO q24h empty stomach (Denamarin??)
Silibinin 2-5mg/kg PO q24h (Nature’s Own, Blackmores 84mg tablets)
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Extrahepatic bile duct obstruction
(EHBDO)
EHBDO in 200 dogs (Cornell)
- 42% pancreatitis
- 14% gallbladder mucocoele
- 13% cholelithiasis
- 12% neoplasia eg adenocarcinoma,mural/extramural ductal or GB neoplasia
- trauma causing common bile duct (CBD) stenosis
- cholecystitis
Ultrasonographic features (of EHBDO):
- Distended gallbladder, cystic duct 24hrs
- Common bile duct 48hrs (<4mm)
- Extrahepatic ducts 72hrs
- Intrahepatic ducts 5-7d
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Biliary tree
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Extrahepatic bile duct
obstruction (EHBDO)
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Extrahepatic bile duct
obstruction (EHBDO)
EHBDO intrahepatic accumulation of potentially toxic bile acids hepatocyte necrosis, apoptosis, biliary fibrosis & cirrhosis
Profound acute increases in ALT, AST, ALP, GGT that progressively rise in first 2 weeks; modest/marked increases in cholesterol
After 4 to 6 weeks of EHBDO enzyme levels improve due to hepatic cirrhosis
Within 8 weeks acquired portosystemic shunting develops
Coagulopathies develop in around 18% of dogs (more common in cats)
PT elevation in 11%, APTT elevation in 8.6%, give vitamin K anyway
May actually be hypercoagulable
BMBT more predictive of intraoperative haemorrhage
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EHBDO due to pancreatitis
Recommend decompression if 7 -10 days (surgical advice) of hyperbilirubinaemia and ultrasound evidence of GB distension, earlier if evidence of systemic compromise, or if not resolving in 3 weeks (medical advice)
Surgical complications:
Systemic endotoxaemia often resistant hypotension
Haemorrhage, stricture, anastomosis breakdown, ascending cholangiohepatitis, gastric ulceration
Surgery may exacerbate pancreatitis
Short term choledochal stenting, 3.5F-12F red rubber catheters with fenestrations
Cholecystostomy tubes: percutaneous endoscopic, laparoscopic; cholecystocentesis
Biliary-enteric anastomoses: cholecystoduodenostomy, cholecystojejunostomy: survival 36-72%. May have reflux post anastomoses, often E Coli. Cyclic illnesses, elevated liver enzymes, fever, leukocytosis
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10 FN Kelpie Cross: Nala
One month history of weight loss, inappetance
Elevated liver enzymes ALP 9137, ALT 1845
Bilirubin 155, neutrophilia 10.8, abnormal cPL
Treatment: IVF, metronidazole, clavulox, enrofloxacin
Abdominal ultrasound: distended gallbladder, distended CBD, cholecystitis, thickened pancreas
4 days later clinically stable but no improvement in bilirubin
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Cholecystitis
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Distended CBD
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Pancreatopathy
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10 FN Kelpie Cross: Nala
Surgery: Bile aspirated submitted for C & S
mild distension of common bile duct and left hepatic bile ducts duodenotomy, major duodenal papilla flushed some biliary sludge, expressed gallbladder
Grossly abnormal liver liver biopsies
After a few days appetite improved, bilirubin dropped to 160
Discharged on enrofloxacin, clavulox, UDCA
Lab results: E Coli from liver tissue culture and bile aspirates resistant to enrofloxacin (which was discontinued)
Liver: chronic cholangiohepatitis, pancreas: normal
6 weeks post operatively bilirubin 51, ALT 900, ALP 7000
Still on clavulox UDCA, SAMe
May need repeat cultures
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13 MN Standard Schnauzer: Henry
Vomiting 6 weeks ago resolved with clavulox
Represented 5 days before with vomiting, inappetance, icterus
T bil 261 (0-7), ALP 13225 (1-150), ALT 2896 (16-90), Chol 21.5 (3.5-9)
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CBD distension
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Pancreatic pseudocyst
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Henry
Surgery: flushing and stenting of bile ducts (with difficulty)
Cholecystitis, septicaemia Enterococcus sp. cultured from blood
2 days later bilirubin 51, 12 days later bilirubin 21, some appetite, discharged
Discharged on: Amoxicillin, Metronidazole, SAMe , UDCA,
4 months later, vomiting, inappetance, no EHBDO
Abdominal carcinomatosis – pts on the table
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