Kiko Acc#161481

1. KikoAcc#161481

2. Kiko • 3yo DSH • 4.2011- Unclassified cardiomyopathy, heart failure ITP-Severe thrombocytopenia with ecchymosis/pechteciation/subdermal hemorrhage Regenerative anemia Hyperglobulinemia Elevated liver/cholestatic enzymes: ALT, ALP, GGT Bilirubinemia Low BUN • AUS- dilated hepatic veins, suspect congestion • Moderate pleural effusion

4. Represented 7.5.11- Elevated liver/cholestatic enzymes: ALT, ALP, GGT,atrDVM- resolved on presentation. • Focal AUS- choledocholithiasis, liver aspirates normal • 11.10.11- 5 days of intermittent anorexia, Bloodwork unremarkable • Ultrasound • Choledocholithiasis • Chronic pancreatitis

6. Cholelithiasis is uncommon in all species except humans • Often incidental • Several risk factors in humans, no definitive risk factors in veterinary patients • Causes malabsorption of vitamin K • Deficiencies of Vit K dependent coagulation factors

7. Cholesterol stones • Pure cholesterol or mixed with material • protein, bilirubin, bile salts and inorganic material • High rates of cholesterol secretion with low rates of bile acid secretion • Cholesterol precipitates around other particles • Salts, sloughed gall bladder mucosal cells, bacteria, bilirubin, parasite fragments and ova • Humans- obesity, high caloric diets, malabsorption of bile acids, estrogens, age, pregnancy, diabetes, high fat diets, N. European or N. or S. American ancestry • Pigment stones • Dried and precipitated bilirubin • Due to increased uncongugatedbilirubin in bile • Humans- hemolysis, alchoholic cirrhosis, biliary infection, age, Oriental ancestry • Calcium carbonate

8. Infection • Bacterial nidus • Cholangiohepatitis can occur secondarily to damage caused by bile duct obstruction • Associated with pancreatitis and IBD in cats d/t bile duct and pancreatic duct both opening into papilla • Extension of enteric bacteria into biliary tree and pancreas most likely source of infection • Foreign material • ova • Hemolysis? • Frequent cause of bilirubincholelithiasis in humans • Liths often 100% bilirubin • Pyruvatekinase deficiency in cats? • Abyssinians and Somalians • Erythrocytes destroyed due to inability to maintain normal metabolism • Cholelithiasis and EHBO may be sequelae to hemolytic anemia (Journal of Feline Medicine and Surgery, 2007)

9. Ultrasound • Mineral? • EHBO- sensitive, though can have false positives • 5mm • Cholangiohepatitis or infiltrative disease can appear sonographically normal

10. Cholangiography • Contrast placed within the gall bladder under ultrasound guidance • Bile peritonitis

11. Cholangiography

12. Retrograde cholangio-pancreatography Gold standard for diagnosing pancreaticobiliary disorders in people Endoscopy and fluoroscopy Less invasive Can be used to remove intraluminal structures, place stents, etc. VRUS, 2005

13. MR cholangiopancreatography • Considered as accurate as retrograde technique without the associated risks T2 FS VRUS 2011

14. CT cholangiography meglumineiotroxate European Radiology, 2007

15. Cholescintigraphy • HIDA scan • hepatobiliaryiminodiacetic acid scan • Radiopharmaceutical concentrates in bile • Can calculate ejection fraction • Fast appropriately to prevent gall bladder contraction • Lack of visualization within the gall bladder implies inflammation- cholecystitis • Delayed transit due to obstruction • ‘Detection of a suspected bronchobiliaryfistula by hepatobiliaryscintigraphy’ • biliptysis

17. Treatment • Antibiotics • EHBO • Surgery • Morbidity and mortality associated with cholecystectomy reported to be low

18. Kiko • Bile and liver aspirates normal • Conservative fluid therapy over the weekend • Hairball?