RADIOGRAPHIC DIAGNOSIS: PERICARDIOPERITONEAL DIAPHRAGMATIC HERNIA AND CHOLELITHIASIS IN A DOG

DIANA S. ROSENSTEIN, DVM, ULLRICH REIF, DVM, Russ L. STICKLE, DVM, GARY WATSON, DVM, WILLIAM SCHALL, DVM, PIERRE AMSELLEM, DVM

Veterinary Radiology & Ultrasound, Vol. 42, No. 4, 2001, p p 308-310.

Signalment Seven year old, neutered, male Shih Tzu

History and Physical Examination The dog had a history of abdominal pain and vomiting of

five days duration. An umbilical hernia had been surgically repaired years earlier. The dog was depressed, lethargic, and had painful palpations of the cranial abdomen. Body tem- perature (39"C), heart rate (1 10 bpm) and respiratory rate (44 breathdmin.) were normal. Heart sounds were clearly audible on the right side and muffled on the left side. There was a neutrophilia with a left shift (1 5,690 segmented neu- trophils/Fl (69%) and 9,100 bands/pl (4%)). Abnormalities on the serum chemistry profile included elevated values for liver enzymes (alkaline phosphatase: 562 I U L (1-90 IUL), aspartate transferase: I90 I U L (10-62 IU/L), alanine trans- ferase: 99 IU/L (1-94 IU/L), hypoalbuminemia of 2.4 g/dl (3.2-4.7 g/dl) and elevated creatinine kinase: 2862 I U L (51-529 IUL)). Radiographs of the thorax and abdomen were obtained (Figs. 1-4).

Radiographic Findings

The cardiac silhouette was enlarged and irregular in shape. There was incomplete visualization of the diaphragm and there were only six sternebrae. A spherical object of mineral opacity was superimposed upon the cardiac silhou- ette (Fig. 1, 2). The stomach was cranially displaced within the abdomen (Fig. 3, 4).

Radiographic Diagnosis

Congenital pericardioperitoneal diaphragmatic hernia with displacement of liver into the pericardial sac. Differ- ential diagnoses for the mineralized object included an in- traluminal intestinal foreign body or a cholelith within the gall bladder, herniated into the pericardial sac.

From the Department of Small Animal Clinical Sciences (Rosenstein, Reif, Stickle, Schall) and Animal Health Diagnostic Laboratory (Watson), College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824- I3 14, and the Small Animal Veterinary Teaching Hospital (Am- sellem), Purdue University, West Lafeyette, IN 47907-7403.

Address correspondence and reprint requests to Dr. Rosenstein. Received November 14, 2000; accepted for publication January 10,

2001.

Surgical Findings

The right medial liver lobe and the gall bladder were displaced through a pericardioperitoneal diaphragmatic her- nia. The gall bladder was necrotic and it ruptured during reduction of the hernia. Its contents included purulent bile and a large cholelith. The common bile duct draining the remaining liver lobes was intact. The herniated liver lobe and the gall bladder were resected, the pericardial sac was lavaged with warm saline (0.09% NaCl) and the diaphrag- matic defect was repaired. Enterococcus sp. was isolated from the gall bladder. Histologically, the gall bladder and resected liver lobe were characterized by necrotizing, sup- purative, and granulating cholecystitis; fibrosing, glissonian capsulitis; hepatitis with pericapsular hemorrhage, and co- alescing bridging portal fibrosis. Antibiotic medication (cephazolin, 20 mgkg IV, every six hours) was adminis- tered during hospitalization. No post-operative complica- tions occurred and the dog was discharged two days after surgery. Antibiotic therapy (cephalexin, 10 mgkg PO, ev- ery eight hours) was continued for seven days. After recov- ery from surgery the dog's clinical signs resolved. Five weeks post-operatively the owner noted that even the occa- sional vomiting, which had been present prior to the acutely painful episode, had not recurred.

Discussion

Pericardioperitoneal diaphragmatic hernia is an uncom- mon congenital anomaly in dogs and cats.'-3 It is associated with other anomalies of the abdominal body wall such as ventral abdominal hernias and sternal abnormalities. ',* The dog in this report had a previously repaired, umbilical hernia and had only six sternebrae. The pericardioperitoneal dia- phragmatic hernia may be incidental in some dogs and clini- cal significance depends on the condition of herniated tis- sues into the pericardial sac.3

Cholelithiasis is also an uncommon condition in dogs and cats that may be clinically silent. Clinical signs of choleli- thiasis are usually evident when there is an associated chole- cystitis, biliary obstruction, or biliary r ~ p t u r e . ~ . ~ Clinical signs of cholecystitis include vomiting. anorexia, polyuria, polydypsia, weight loss, icterus, fever, and abdominal

A cholelith may be visible on abdominal radio-

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VOL. 42, No. 4 RADIOGRAPHIC DIAGNOSIS 309

Fig. I . Right lateral radiograph of the thorax. The cardiac silhouette is enlarged and irregular, the diaphragm is not completely visualized and only six sternebrae are present. A round, mineral opacity is superimposed upon the cardiac silhouette.

Fig. 3. Right lateral radiograph of the abdomen. The stomach is crani- ally displaced in these abdomen and there is incomplete visualization of the diaphragm.

Fig. 2. Ventrodorsal thoracic radiograph. The mineral opacity is spheri- Fig. 4. Ventrodorsal radiograph of the abdomen. The stomach is crani- cal and superimposed on the enlarged cardiac silhouette. ally displaced and there is incomplete visualization of the diaphragm.

310 ROSENSTEIN ET AL. 200 1

graphs although not all choleliths are radiopaque. Pure cho- lesterol choleliths are radiolucent, pigment stones and choleliths of mixed contents are variable in opacity and calcium bilirubinate choleliths are r a d i o p a q ~ e . ~ . ~ The cholelith in this dog was comprised of calcium carbonate. In this dog, herniation of the gall bladder and liver lobe into the pericardial sac may have contributed to formation of the cholelith and was likely associated with the cholecystitis and hepatitis. Cholecystectomy is indicated for treatment of cholelithiasis with chole~ysti t is .~.~ Microbial culture of bile or gall bladder tissue is recommended as an underlying infection is ~ o m m o n . ~ ’ ~ Escherichia coli, Streptococcus sp.,

Enterococcus sp., and Klebsiella sp. are common bacterial agents in infectious cholecystitis. Specific antimicrobial sensitivity should be determined for selection of appropriate antibacterial medication, however, if this is not available, then empirical medication may include a first-generation cephalosporin, fluoroquinolones, or ampicillin!

The dog in this report was unique in that two, potentially incidental abnormalities, pericardioperitoneal diaphrag- matic hernia and cholelithiasis, were present simultaneously and that both conditions contributed to the dog’s medical problem. Surgical management by cholecystectomy and herniorrhaphy led to complete resolution of the clinical signs.

REFERENCES

I . Suter PF. Thoracic radiography: A text atlas of thoracic diseases of the dog and cat. Wettswil: PF Suter, 1984;194-195.

2. Wallace J, Mullen HS, Lesser MB. A technique for surgical correc- tion of peritoneal pericardial diaphragmatic hernia in dogs and cats. J Am Anim Hosp Assoc 1992;28:503-510.

3. Evans SM, Biery DN. Congenital peritoneopencardial diaphragmatic hernia in the dog and cat: a literature review and 17 additional case his- tones. Vet Radial 1980;21:108-116.

4. Kirpensteijn J, Fingland R, Ulrich T, Sikkema D, Allen S. Cholelithiasis in dogs: 29 cases (1980-1990). J Am Vet Med Assoc 1993;202:1137-1142.

5. Johnson SE. Cholelithiasis and cholangitis. In: Kirk RW (Ed.), Cur- rent Veterinary Therapy X: Small Animal Practice. Philadelphia: WB Saunders, Co., 1989;884-889.

6. Walshaw R. Liver and biliary system: surgical diseases. In: Slatter DH (Ed.), Textbook of Small Animal Surgery. Philadelphia: WB Saunders, Co., 1985;807-812.