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Bile Peritonitis

Bile Peritonitis. Signalment. Tanner, 6.5 yo MC Cocker Spaniel. History. 1 week history of vomiting (yellow liquid), diarrhea, anorexia Has been seen at rDVM for 1 week with inc ALP, ALT, GGT, T-bili, dec BUN, glucose, elevated bile acids, fever, inflammatory leukogram

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Bile Peritonitis

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  1. Bile Peritonitis

  2. Signalment • Tanner, 6.5 yo MC Cocker Spaniel

  3. History • 1 week history of vomiting (yellow liquid), diarrhea, anorexia • Has been seen at rDVM for 1 week with inc ALP, ALT, GGT, T-bili, dec BUN, glucose, elevated bile acids, fever, inflammatory leukogram • Has been treated with enrofloxacin, metronidazole, famotidine and maropitant

  4. Physical Exam Findings • Abdomen tense and painful (1-2/4) on palpation • Obese • T: 103.2F P: 132bpm R: 24 br/min • CRT <2sec Wt 17.6kg BCS: 7/9

  5. Clinical Pathology • CBC: marked leukocytosis (62.51K/uL RR: 4.39-11.61) characterized by a neutrophilia (51.883K/ul RR: 2.841-9.112) with a regenerative left shift (1.250K/ul bands) and monocytosis (8.126K/ul RR: 0.075-0.85). Mild microcytic, hypochromic anemia (Hct = 32.1%). Thrombocytopenia (150K/uL) with increased MPV. Mild hypoproteinemia (5.8 g/dL RR: 6.1-7.5).

  6. Clinical Pathology • Chemistry Panel: • Markedly elevated ALP (3804 IU/L), mildly elevated ALT, GGT and T-bili, hyperphosphatemia, hypocalcemia, hypomagnesemia, hypoalbuminemia, low normal glucose, low normal BUN. Electrolytes are within normal limits.

  7. Clinical Pathology • Resting Ammonia: Increased at 43 umol/L (RR: 3-30). • Bile Acids Tolerance: Increased resting and post-prandial levels (pre = 55.7, post = 71.5 umol/L RR: 25) • Coagulation Profile: High normal PT, prolonged PTT. D-dimers 500-1000 ng/ml. Thrombocytopenia.

  8. Liver

  9. Liver

  10. Liver

  11. Hepatic lymph nodes

  12. Hepatic lymph node

  13. Gall bladder

  14. Gall bladder

  15. Gall bladder

  16. Gall bladder

  17. Right Adrenal

  18. Abdominal Ultrasound • Probable hepatic cirrhosis - no evidence of portal hypertension • Biliary mucocele • Hepatic lymphomegaly - probable reactive hyperplasia • Right adrenomegaly - hyperplasia vs. neoplasia

  19. Abdominal Fluid Analysis • Highly cellular specimen with large numbers of inflammatory cells with a pale blue to green mucinous material that is consistent with bile. Rare bilirubin crystals noted. Inflammatory cells consist of 84% slightly degenerate neutrophils and 16% activated macrophages. • Interpretation/assessment: Bile peritonitis with marked suppurative inflammation • Bilirubin: 1.5mg/dL (Serum 2.0mg/dL)

  20. Outcome • Owners elected to euthanize based on the diagnosis of bile peritonitis • Necropsy: Microhepatica with diffuse nodules, distended gall bladder with inspissated brown-green mucoid material and rupture of the common bile duct, fibrin at the defect and diffusely throughout abdomen, bile and inflammation throughout the mesentery, thoracic lymphadenopathy

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