Diseases of the gallbladder and biliary tree. Vet Clin North Am Small Anim Pract. 2009;39:543-598. [PMID: 19524793 DOI: 10.1016/j.cvsm.2009.01.004]

Contribution of ultrasound examination in diagnosing platynosomiasis and correlation with macro and microscopic findings in callitrichids kept under human care

BACKGROUND

Platynosomiasis in non-human primates kept under human care causes chronic disease of the bile ducts and liver, which initially presents with nonspecific signs and can culminate in the death of the animal. Diagnosing this disease is a challenge, and an ultrasound examination can be an excellent tool when it is suspected.

METHODS

This study describes the ultrasound findings from 57 marmosets with suspected infection by Platynosomum sp., the correlated hepatobiliary changes, and the anatomopathological findings that confirmed the occurrence of platynosomiasis.

RESULTS

In six marmosets (one C. aurita, two C. jacchus, and three Callithrix sp.), Platynosomum infection was confirmed macroscopically (presence of adult trematodes in the gallbladder) and microscopically (adults, larvae, and eggs in histological examinations and eggs in bile and feces). These findings were compatible with the hepatobiliary changes and with images suggestive of parasitic structures in ante-mortem assessments.

CONCLUSION

Ultrasound examination demonstrated its usefulness within the clinical routine for investigating this parasitosis.

Clinical use of uncovered balloon-expandable metallic biliary stents for treatment of extrahepatic biliary tract obstructions in cats and dogs: 11 cases (2012-2022)

OBJECTIVE

To describe the application of uncovered balloon-expandable metallic biliary stents for treatment of extrahepatic biliary obstructions (EHBOs) and the outcomes for dogs and cats treated for EHBO with this technique.

STUDY DESIGN

Retrospective single institutional study.

ANIMALS

Eight dogs and three cats treated at the Veterinary Specialty Hospital of San Diego for EHBO between January 2012 and February 2022.

METHODS

Data collected from the medical records included signalment, presenting complaint, laboratory and imaging findings, surgical findings, hospitalization time, complications, and follow-up information.

RESULTS

Median duration of short-term follow up was 16 days (6-45 days). Improved biochemical abnormalities and resolution of clinical signs were recorded in 10/11 cases. Two dogs died within 2 weeks of surgery. One dog developed systemic inflammatory response syndrome 5 days postoperatively and was euthanized; the cause of death in the second case was unknown. Long-term follow up was available in seven cases, with a median duration of 307.5 days (62-2268 days). Bile-duct patency was maintained for at least 356-622 days (median: 446 days) in three cats and 62-2268 days (median: 650.5 days) in four dogs with long-term follow up available. One cat had recurrent obstruction with choledocholiths 446 days postoperatively. One stent was removed 614 days postoperatively due to recurrent cholangiohepatitis.

CONCLUSION

Uncovered balloon-expandable metallic biliary stents were placed successfully and relieved EHBO in all cases that survived to discharge.

CLINICAL SIGNIFICANCE

Use of uncovered balloon-expandable metallic biliary stents should be considered as an alternative to temporary choledochal luminal stenting or cholecystoenterostomy to manage EHBO.

Concurrent hepatopathy in dogs with gallbladder mucocele: Prevalence, predictors, and impact on long-term outcome

BACKGROUND

Information is limited regarding the prevalence and importance of hepatic histologic abnormalities in dogs with gallbladder mucocele (GBM).

OBJECTIVES

To (a) report prevalence of hepatic histologic abnormalities in dogs with GBM (b) evaluate for association between hepatic abnormalities and outcome in dogs with GBM (c) evaluate whether neutrophil-to-lymphocyte ratio (NLR) differs in dogs with GBM with and without specific hepatic lesions.

ANIMALS

Fifty-two dogs with grossly and histologically confirmed GBM.

METHODS

Multicenter, retrospective study of dogs with GBM undergoing cholecystectomy with concurrent liver biopsy. Archived histological sections of gallbladder and liver evaluated by investigators blinded to data. Proportions of dogs with each histologic abnormality alive vs deceased at 1, 3, and 12 months post-cholecystectomy compared. Mann-Whitney U performed to determine if NLR differed in dogs with or without selected lesions.

RESULTS

51/52 (98%, 95% CI [89%, 99%]) dogs with GBM had at least 1 hepatic histologic abnormality. Hepatic fibrosis (37/51; 73%, 95% CI [59%, 83%]), biliary hyperplasia (29/52; 56%, 95% CI [42%, 68%]), and portal inflammation (25/52; 48%, 95% CI [35%, 61%]) were most common. The proportion of dogs alive vs dead differed based on the fibrosis score at 1, 3, and 12 (P ≤ .04) months post-cholecystectomy. Dogs with hepatic necrosis (P = .006) and cholangitis/cholangiohepatitis (P = .02) had higher NLRs compared to dogs without these lesions.

CONCLUSIONS AND CLINICAL IMPORTANCE

Histologic abnormalities of the liver are common in dogs with GBM. A higher portal fibrosis score might be associated with shortened long-term survival after cholecystectomy for dogs with GBM. An increase in NLR might predict hepatic necrosis and cholangitis/cholangiohepatitis in dogs with GBM.

MUC5AC and MUC5B expression in canine gallbladder mucocele epithelial cells

Gallbladder mucocele (GBM) is one of the most common gallbladder diseases in dogs. Its pathogenesis has not yet been clarified, but excessive accumulation of a secretory gel-forming mucin, MUC5AC in the gallbladder has been reported. This study aimed to ascertain if MUC5AC overproduction resulted in mucus accumulation in the gallbladder during GBM development. Eleven dogs undergoing cholecystectomy who were pathologically diagnosed with GBM were included, and the expression level of mucins, particularly MUC5AC and MUC5B, in their gallbladder epithelial cells was compared with those in normal gallbladder epithelial cells. On reverse transcription-quantitative polymerase chain reaction screening, there was a significant difference (P<0.05) in the mRNA expression level of MUC1, but not of other mucins including MUC5AC and MUC5B, between mucocele and normal gallbladder epithelial cells. Protein expression levels were also evaluated for MUC5AC and MUC5B using immunohistochemistry. There was little immunoreactivity for MUC5AC, whereas MUC5B showed definitive staining in gallbladder epithelial cells. There was no difference in MUC5AC and MUC5B protein expression levels between mucocele and normal gallbladder epithelial cells. These data suggest that excessive production of mucin, especially MUC5AC and MUC5B, does not occur in canine GBM, and that abnormal mucus excretion, rather than excessive mucus production, may be the cause of GBM development.

Prevalence and clinical relevance of cholelithiasis in cats: A multicenter retrospective study of 98 cases

BACKGROUND

Cholelithiasis is an uncommon and mainly incidental finding in dogs; current literature on this topic is scarce in cats.

HYPOTHESIS

Report prevalence, clinical presentation, management, and outcome of cholelithiasis in cats.

ANIMALS

Ninety-eight cats with cholelithiasis.

METHODS

Retrospective multicenter case series. Electronic databases from 3 hospitals were searched for cats diagnosed with cholelithiasis by ultrasonography (US). Cholelithiasis was classified as incidental (IC) or symptomatic (SC) depending on clinicopathological signs, biliary tract US appearance, and presence of another disease potentially explaining the clinical presentation. Multivariate analysis was used to investigate factors associated with clinical expression of cholelithiasis and, within the SC group, survival.

RESULTS

The observed prevalence of cholelithiasis was 0.99% (95% confidence interval [CI], 0.79%-1.19%) among cats that underwent abdominal US. Cholelithiasis was classified as IC in 41% and SC in 59%. Choleliths found in multiple locations within the biliary tract (odds ratio [OR], 8.11; 95% CI, 2.32-34.15; P = .001) or associated with US signs of obstruction (OR, 18.47; 95% CI, 2.13-2413.34; P = .004) were significantly associated with SC. Concurrent hepatobiliary diseases were suspected or confirmed in 83% of cases with SC. Forty-three cats (74%) with SC survived to discharge. Biliary tract obstruction (BTO) was negatively associated with survival (OR, 13.87; 95% CI, 1.54-124.76; P = .001). None of the cats with IC that had available follow-up (47%) developed clinicopathological signs related to cholelithiasis.

CONCLUSIONS AND CLINICAL IMPORTANCE

Cholelithiasis is uncommon and can be asymptomatic in cats. Symptomatic cholelithiasis frequently is associated with another hepatobiliary disease or BTO or both. Biliary tract obstruction is associated with poorer outcome.

Surgical Management Of Feline Biliary Tract Disease: Decision-making and techniques

PRACTICAL RELEVANCE

Diseases of the hepatobiliary system are not uncommon in first-opinion practice. The anatomy of the feline hepatobiliary tract differs from that of dogs and may predispose cats to inflammatory hepatobiliary disease. Case management can be challenging, and the prognosis is variable and dependent on the underlying disease process.

CLINICAL CHALLENGES

Biliary tract disease in the cat has non-specific clinical signs that overlap with those of diseases of other body systems. Diagnostic tests of the hepatobiliary system are widely available, but interpretation of results can be challenging. Deciding on medical or surgical management can also be challenging; for example, various degrees of cholestasis may be seen with different diseases and disease severities, and will influence the decision to manage the patient medically or surgically. Surgery is indicated in cases of bile peritonitis, severe cholestasis, focal neoplasia or disease that is refractory to medical management. Intensive perioperative and postoperative management, with 24 h hospitalisation facilities, is essential.

AUDIENCE

This review article is written for the small animal general/primary care practitioner, with an emphasis on decision-making in the surgical management of feline hepatobiliary disease.

EVIDENCE BASE

Evidence available in the published literature is reviewed and presented, and the inherent limitations are discussed.

Microbiome analysis of bile from apparently healthy cats and cats with suspected hepatobiliary disease

BACKGROUND

Bacterial infection of bile is a common cause of hepatobiliary disease in cats. Whether bile harbors a core microbiota in health or in cases of suspected hepatobiliary disease in cats is unknown.

OBJECTIVES

Establish if gallbladder bile in apparently healthy cats harbors a core microbiota composed of bacterial taxa common to many individuals. Compare results of bile cytology, bile culture, and 16S rRNA gene amplicon sequencing in apparently healthy cats and cats with suspected hepatobiliary disease.

ANIMALS

Forty-three client-owned cats with suspected hepatobiliary disease and 17 control cats.

METHODS

Bile was collected by ultrasound guided cholecystocentesis (cats with suspected hepatobiliary disease) or laparotomy after euthanasia (controls). Bile samples underwent cytologic examination, aerobic and anaerobic culture, and DNA was extracted for 16S rRNA gene amplification and sequencing.

RESULTS

Microbiome sequencing did not identify a core microbiota in control cats or cats having bile sampled because of clinical suspicion for hepatobiliary disease. Microbiome profiles from control cats were indistinguishable from profiles obtained from sampling instruments and reagents that were not exposed to bile (technical controls). Bacterial taxa that could not be explained by contamination or off-target amplification were identified only in samples from cats with bactibilia and positive bile culture results for Escherichia coli. In several E. coli positive samples, microbiome sequencing also identified a small number of potentially co-infecting bacterial genera not identified by culture.

CONCLUSIONS AND CLINICAL IMPORTANCE

Cat bile does not harbor a core microbiota. Uncultured bacteria may contribute to pathogenesis of hepatobiliary disease in cats with bile E. coli infection.

Serum Bile Acids Concentrations and Liver Enzyme Activities after Low-Dose Trilostane in Dogs with Hyperadrenocorticism

Hyperadrenocorticism (HAC) often leads to vacuolar hepatopathy. The impact of trilostane treatment on serum total bile acids (SBAs) concentrations in dogs with HAC remains unknown. This study investigated SBAs concentrations in healthy dogs and those with HAC following trilostane therapy. Ten healthy dogs and fifteen dogs with HAC were prospectively enrolled. A biochemistry profile and pre- and post-prandial SBAs concentrations were determined in each dog. Dogs with HAC were reassessed at 1 and 3 months after the initiation of trilostane treatment. Dogs with HAC had significantly higher serum ALT, ALP, and GGT activities, and cholesterol, triglyceride, and pre-prandial SBAs concentrations compared to healthy dogs. After 3 months of trilostane treatment, polyuria/polydipsia and polyphagia were completely resolved in 42.8% and 35.7%, respectively. Significant improvements in serum ALT and ALP activities and cholesterol concentrations were observed within 1-3 months of trilostane treatment. However, pre- and post-prandial SBAs concentrations did not significantly decrease. These findings suggest that treatment with low-dose trilostane for 3 months appears to reduce serum liver enzyme activities, but not SBAs concentrations. Further investigation is warranted to explore the effects of low-dose trilostane treatment on SBAs concentrations for a longer duration or after achieving appropriate post-ACTH cortisol levels.

Ultrasonographic measurement of gallbladder wall thickness in fasted dogs without signs of hepatobiliary disease

BACKGROUND

Ultrasound-determined gallbladder wall thickness is widely used to aid in the diagnosis of gallbladder disease, but no reference values supported by published measurement data are available in dogs.

HYPOTHESIS/OBJECTIVE

Establish normal thickness of the gallbladder wall in dogs.

ANIMALS

Fifty-three dogs presented to a referral hospital and required abdominal ultrasound examination for reasons unrelated to primary hepatobiliary disease.

METHODS

Cross-sectional observational study recruiting dogs requiring abdominal ultrasound examination. A standard sequence of gallbladder wall images was recorded for later review. Inclusion criteria were normal ultrasonographic hepatobiliary, pancreatic, and small intestinal findings. Exclusion was determined by 2 European College of Veterinary Internal Medicine (ECVIM)-certified veterinary internists blinded to gallbladder wall thickness data. Dogs were excluded if they had inadequate medical records, a previous history of hepatobiliary, gastrointestinal, or pancreatic disease likely to impact the biliary system (eg, chronic vomiting, nausea, jaundice, diarrhea), unexplained increases in liver enzyme activities, hypoalbuminemia, or ascites. Gallbladder wall thickness was determined by 2 European College of Veterinary Diagnostic Imaging (ECVDI)-certified veterinary radiologists working together to generate a consensus for each dog. The final output was the maximum normal wall thickness for this population of dogs.

RESULTS

The upper limit for gallbladder wall thickness in 53 fasted (8 hours) dogs <40 kg was 1.30 mm (90% confidence interval, 1.19-1.41).

CONCLUSIONS AND CLINICAL IMPORTANCE

Normal gallbladder wall thickness in dogs is lower than previously reported. Additional studies are required to determine potential effects of body weight and the optimal cut-off to distinguish between healthy and diseased gallbladders.

Feasibility of Magnetic Resonance Cholangiopancreatography in Dogs-A Post-Mortem Study

Magnetic resonance cholangiopancreatography (MRCP) is commonly used in humans and is also feasible in cats. The aim of this post-mortem study was to investigate the feasibility of MRCP in eight adult dogs by comparing the visibility and measured diameters of the biliary tract and pancreatic ducts in MRCP with those of fluoroscopic retrograde cholangiopancreatography (FRCP) and corrosion casting. In autopsy, six dogs had no evidence of hepatobiliary disorders, one had pancreatic pathology, and one had biliary pathology. The gallbladder (GB), cystic duct, and common bile duct (CBD) were visible in the MRCP images of all eight dogs. However, the extrahepatic ducts and pancreatic ducts were only variably visible. There was statistical agreement between MRCP and FRCP in measuring the diameters of the GB (fundus and body) and CBD (at papilla and extrahepatic ducts' junction). The diameter measurements correlated between MRCP and corrosion casting. Our study showed that MRCP is feasible in dogs and allowed for proper visualization of the biliary tract. However, ducts with diameters of <1 mm were difficult to visualize using a 1.5 Tesla MRI machine. Further studies are warranted to apply MRCP in the diagnostic imaging of live dogs.

CT features of divisional bile ducts in healthy Labrador Retrievers

Computed tomography (CT) is increasingly being used for the study of gallbladder and bile duct diseases. The first step in interpreting CT findings is understanding the cross-sectional anatomy of the structures involved, but there are no published studies describing the CT features of the divisional bile ducts. In dogs, anatomic studies report two common patterns including three or four divisional bile ducts. The aim of this retrospective, descriptive, anatomical study was to describe the size and pattern of the visible divisional bile ducts, based on their location and extension, using contrast-enhanced CT in a group of Labrador Retrievers without evidence of hepatobiliary diseases. The correlation between the biliary duct number and dimensions, and the visceral fat area percentage (VFA%) was also evaluated. The right lateral divisional duct (RLD) was visualized in four of 40 dogs, the left lateral divisional duct (LLD) in nine of 40 dogs, and in 17 of 40 dogs, both were simultaneously visualized. In 10 of 40 dogs, the RLD and LLD were not highlighted. When visible, the RLD has a median diameter of 0.23 cm and a median length of 0.82 cm. The LLD has a median diameter of 0.23 cm and a median length of 2.72 cm. The median diameter of the common bile duct before and after the insertion of divisional bile ducts was 0.23 and 0.25 cm, respectively. No correlation with the VFA% was found. At least one of the divisional bile ducts could be visualized using contrast-enhanced CT in the majority of sampled dogs (75%) .

Ultrasound appearance of the duodenal papilla in clinically healthy cats

OBJECTIVES

The duodenal papilla (DP) is an anatomical structure located in the duodenal wall, a few centimetres from the pylorus. In cats, the pancreatic and bile ducts merge as they enter the DP, and this explains why cats are more likely than dogs to have concomitant digestive, pancreatic and hepatic infections. Ultrasonography of the DP has been previously established in dogs but not in cats. The purpose of our prospective study was to describe the ultrasound features of the DP in 30 adult clinically healthy cats.

METHODS

A full abdominal ultrasound was performed. Five measurements were recorded: the width and the height in a transverse section; the length and the height in a longitudinal section; and the thickness of the duodenal wall adoral to the DP in a longitudinal section. The subjective appearance (echogenicity and shape) of the DP was described.

RESULTS

The dimensions of the DP were a mean ± SD width of 3.13 ± 0.68 mm and height of 2.47 ± 0.63 mm in the transverse section, and length of 3.98 ± 1.27 mm and height of 2.44 ± 0.57 mm in the longitudinal section. The DP was homogeneous, subjectively isoechoic to fat and had a round and oval shape in the transverse and longitudinal sections, respectively. There was no correlation between the DP measurements and the weight, age or sex of the cats. The animals that were fed a mixed diet had a longer DP than those fed dry food.

CONCLUSIONS AND RELEVANCE

This study provides reference values for the dimensions of the DP, as well as information on its ultrasonographic appearance in clinically healthy adult cats. We did not find any correlation between the age of the cats and the size of the papilla, but the age range was small and another study in older cats should be undertaken to address this more thoroughly.

Feline Cyst-like Lymphocytic Cholangiohepatitis in a Cat: First Case Report

A 5-year-old female neutered domestic short-haired cat presented with abdominal enlargement. An abdominal ultrasound revealed that large multiple hepatic cysts with irregular walls, hypoechoic fluid, and internal septations occupied most of the liver parenchyma. Serum liver enzymes, bilirubin, and bile acids concentrations were within normal limits. A fecal examination using simple floatation and formalin-ether sedimentation techniques was negative for liver fluke (Platynosomum fastosum), intestinal protozoa, and other helminth eggs. Praziquantel was prescribed for two distinct courses one month apart without obvious improvement of the hepatic cysts. An abdominal laparotomy and histopathological examination finally enabled diagnosis of cyst-like lymphocytic cholangiohepatitis of the liver tissue. Twelve weeks of oral prednisolone resulted in marked ultrasonographic improvement of the hepatic cysts. The liver parenchyma was heterogeneous and filled with multiple small anechoic cavities. Twenty-three months after ceasing the prednisolone, there was no recurrence of hepatic cysts.

Ultrasonographic prevalence and proposed morphologic classification of bilobed gallbladder in cats

OBJECTIVES

Morphologic anomalies of the feline gallbladder (GB) have been previously reported in the literature. These morphologic variants are frequently encountered on routine abdominal ultrasound examination. The aim of this study was to provide an ultrasonographic classification system of these variants and document the overall incidence in the feline population.

METHODS

A prospective, descriptive study was undertaken; cats that had an abdominal ultrasound examination that included at least one sagittal and transverse plane image of the GB were included. GB shape was evaluated and categorized based on a classification scheme of morphologic variants modified from the human literature. Septated (S), bilobed (B1, B2, B3), duplex (D) and complex (C) categories were described.

RESULTS

Of 516 cats included in the study, 389 had normal GB morphology, while 127 had anomalous GB morphology. The overall incidence rate of anomalous GB morphology was 24.61%. When examined by morphologic type, the septated (S) morphology had an incidence of 9.69%. A bilobed (B) morphology was the most commonly observed classification; incidence was 14.35% within our population; incidence of B1, B2 and B3 subtypes were 2.91%, 6.98% and 4.46%, respectively. Duplex GBs only made up 0.39% of the total population. The incidence of complex (C) morphologies was 0.19%.

CONCLUSIONS AND RELEVANCE

The incidence of GB morphologic anomalies was higher in our population than previously reported. Identification of these anomalies on routine ultrasound evaluation is common; numerous different morphologies can be identified and a standardized classification scheme is proposed. Complete evaluation of morphology can be challenging, particularly with regard to cystic duct anatomy. Clinical significance is uncertain and future studies are warranted to determine the relationship between morphologic variants and hepatobiliary disease.

Dietary Supplemental Chromium Yeast Improved the Antioxidant Capacity, Immunity and Liver Health in Broilers under High Stocking Density

This study was conducted to investigate the effects of different levels of yeast chromium on growth performance, organ index, antioxidant capacity, immune performance and liver health of broilers under high stocking density. A total of 684 1-day-old Arbor Acres broilers were selected and fed a common diet from 1 to 22 days of age. At the end of 22 days, broilers with similar weight were randomly divided into six treatments, with six replications in each treatment. The broilers in control groups were fed with a control diet and raised at low stocking density of broilers (14 broilers/m2, LSD) and high stocking density (20 broilers/m2, HSD). The broilers in treatment groups were fed with diets supplemented with 200, 400, 800 and 1600 µg Cr/kg chromium yeast (Cr-yeast) under HSD, respectively. The experimental period was 23~42 days. Compared with the LSD group, the HSD group significantly decreased the liver index (ratio of liver weight to live weight of broilers) of broilers (p < 0.05), the HSD group significantly increased the content of corticosterone (CORT) and the activities of alanine aminotransferase (ALT) and alkaline phosphatase (ALP) and decreased the prealbumin (PA) level in the serum (p < 0.05). HSD decreased the total antioxidant capacity (T-AOC) contents in the serum, liver and breast, serum glutathione peroxidase (GSH-Px) activities, breast total superoxide dismutase (T-SOD) activities and liver catalase (CAT) activities of broilers (p < 0.05). The HSD group significantly increased the total histopathological score (p < 0.05). Compared with the HSD group, adding 200, 400, and 1600 Cr-yeast significantly increased the liver index of broilers (p < 0.05), all HSD + Cr-yeast groups decreased the ALT activities (p < 0.05), and the HSD + 800 group significantly decreased the CORT contents and the ALP activities of the serum (p < 0.05); the HSD + 400, 800 and 1600 groups increased the PA contents of the serum (p < 0.05); HSD + 800 group significantly reduced the tumor necrosis factor-α (TNF-α) and Interleukin-1β (IL-1β) contents of the serum (p < 0.05); moreover, the HSD + 400 group increased the GSH-Px activities of the serum (p < 0.05), the T-AOC and the T-SOD activities of the breast (p < 0.05) and the T-AOC and CAT activities of the liver (p < 0.05). Adding 800 Cr-yeast significantly decreased the total histopathological score (degree of hepatocyte edema and inflammatory cell infiltration) under HSD (p < 0.05). In summary, Cr-yeast can improve the antioxidant capacity and immune traits, and liver health of broilers under HSD. Based on the results of the linear regression analysis, the optimal supplementation of Cr-yeast in antioxidant capacity, immunity ability and liver health were at the range of 425.00−665.00, 319.30−961.00, and 800.00−1531.60 µg Cr/kg, respectively.

Multidrug resistant Enterococcus faecium isolate from cholangitis/cholecystitis in a dog

Mucocele and cholecystitis were diagnosed in a 10 year-old Shetland-sheepdog presenting aspecific clinical signs. Blood examinations and ultrasonography investigation were performed before to surgical approach, which allowed to collect biopsies and samples for bacteriological analyses. In addition, the patient was subjected to cholecystectomy. A multidrug resistant Enterococcus faecium was isolated from the gallbladder specimens. On the basis of antimicrobial susceptibility test, nitrofurantoin was used. The correct bacteriological diagnosis is necessary to set up effective therapy, influencing the patient's prognosis and improving the recovery time.

Feline cholangitis/cholangiohepatitis complex - what have we learned?

Cholangitis/cholangiohepatitis complex in cats is commonly encountered in clinical practice worldwide. Diagnosis and management of cats with this complex is difficult because of the ambiguity of clinical signs, diagnostic test results and commonality of comorbid disorders. These impediments can delay disease identification and treatment, which can increase morbidity and mortality. ​In this narrative review, we aimed to provide a thorough review of the unique physioanatomic features of the biliary system as well as clinically relevant updates on cholangitis/cholangiohepatitis complex in cats.

Diagnostic value of endoscopic retrograde cholangiopancreatography and therapeutic value of endoscopic sphincterotomy in dogs with suspected hepatobiliary disorders

Background

Conventional diagnostic methods have some limitations in diagnosing specific causes of canine hepatobiliary disorders. In the evaluation of the hepatobiliary system in dogs, ultrasonography (US) is the first imaging method of choice. Nonetheless, endoscopic retrograde cholangiopancreatography (ERCP) has also been proven to be a practicable technique for evaluating canine hepatobiliary (endoscopic retrograde cholangiography, ERC) and pancreatic duct (endoscopic retrograde pancreatography, ERP) disorders, providing additional therapeutic options by sphincterotomy (EST). To date, the efficacy and safety of diagnostic and therapeutic ERCP has not been evaluated in veterinary medicine literature. The present study sought to report complications and outcomes of dogs undergoing ERCP and EST, and to assess the usefulness of diagnostic ERCP by comparing the findings of US, ERCP and histopathological findings in liver and pancreas.

Results

This retrospective case series comprises data collected from 15 dogs that underwent successful ERC/ERCP. Nine dogs underwent EST following ERC. US and ERC were best in agreement when assessing the common bile duct. In case of disagreement between the modalities, the ERC findings of the ductal structures were in line with the available pathology findings more often than the US findings, whereas the opposite was noted for the gallbladder. The technical success rates were 88.2% for ERC, 66.7% for ERP, and 81.8% for EST, with no major complications during or immediately after the procedure. Immediate bile flow after EST was recorded in 7/9 dogs but only four showed coinciding clinical and laboratory improvement and four dogs were euthanized within 1-6 days after EST.

Conclusions

US remains a valuable initial diagnostic imaging method for hepatobiliary disorders and allows good assessment of the gallbladder. ERC can serve as a complementary procedure for diagnostic assessment of the hepatobiliary duct disorders. However, in order to improve the outcomes of EST, careful selection of patients for the procedure would require more advanced diagnostic imaging of the hepatobiliary area.

Chronic cholecystitis: Diagnostic and therapeutic insights from formerly bile-farmed Asiatic black bears (Ursus thibetanus)

Across Southeast Asia and China, more than 17000 Asian bears are kept under suboptimal conditions and farmed for their bile to meet the consumer demand for traditional medicine products. Years of unsterile and repetitive bile extraction contribute to the development of chronic sterile or bacterial cholecystitis, a pathology commonly diagnosed in formerly bile-farmed bears. In both human and veterinary medicine, the diagnostic value of the macroscopic bile examination for assessing gallbladder disease is unclear. The objective of this study is to identify the role of gallbladder bile color, viscosity, and turbidity, while comparing them with established markers of cholecystitis. Moreover, it aims to define the optimal duration of oral antibiotic treatment for chronic bacterial cholecystitis in bears associated with bile farming. Thirty-nine adult, formerly bile-farmed Asiatic black bears (Ursus thibetanus) were examined under anesthesia and underwent percutaneous ultrasound guided cholecystocentesis. A total of 59 bile samples were collected with 20 animals sampled twice to evaluate the therapeutic success. All bile aspirates were assessed macroscopically and microscopically followed by submission for bacterial culture and antimicrobial sensitivity. In the majority of bears, samples with cytological evidence of bactibilia lacked inflammatory cells and did not always correlate with positive bacterial cultures. The most common bacterial isolates were Enterococcus spp, Streptococcus spp and Escherichia coli. Based on our findings, the optimal duration of antibiotic treatment for chronic bacterial cholecystitis is 30 days. Moreover, unlike Gamma-glutamyl Transferase (GGT) and gallbladder wall thickness, the organoleptic properties of bile were found to be reliable markers of chronic gallbladder inflammation with color and turbidity indicating cholestasis. The current study highlights the importance of cholecystocentesis for the management of gallbladder disease and provides initial results on the possible diagnostic value of macroscopic bile examination.

Canine extrahepatic biliary disease: what have we learned?

Extrahepatic biliary disease in dogs is commonly encountered in clinical practice worldwide. Diseases in this segment of the biliary tract are diverse and can manifest with mild clinical signs or can be life-threatening. In the last decade there have been advances in diagnostic tests, imaging modalities and therapeutic interventions as well as the identification of novel prognostic variables that could improve outcomes in dogs with extrahepatic biliary disease. Therefore, the objective of this review was to summarise clinically relevant updates of extrahepatic biliary disease in dogs.

Novel Multicentric Hepatic Lymphoma with Extrahepatic Biliary Obstruction Associated with Duodenal Perforation in a Cat

An 11-year-old male castrated domestic shorthair cat was presented for evaluation due to clinical deterioration and potential extrahepatic biliary obstruction (EHBO). Further investigations confirmed EHBO and revealed severe and previously unreported comorbidities. On initial examination, the cat was markedly icteric with a poor body condition score and severe muscle wasting. Serum chemistry and complete blood count showed evidence of cholestasis and anemia. Primary diagnostics and therapeutics targeted these abnormalities. Abdominal ultrasound revealed peritoneal effusion, multifocal mixed echogenic hepatic and splenic foci, small intestinal thickening, cholelithiasis, choledocholithiasis, and common bile duct and pancreatic duct dilation with evidence of obstruction. Peritoneal effusion cytology confirmed septic peritonitis. Hepatic and splenic cytology was consistent with lymphoma. Based on these results, euthanasia was elected by the owners of the animal. Necropsy confirmed the ultrasound diagnoses, septic peritoneal effusion associated with a duodenal perforation, multiorgan lymphoma, and common bile duct carcinoma. Flow cytometry classified the lymphoma as a double-negative phenotype of T-cell lymphoma (CD3+ and CD5+, but CD4- and CD8-) present in the duodenum and liver and suspected in the spleen which has previously not been reported in cats. This case report documents a cat with EHBO caused by multiple disease processes including a novel T-cell lymphoma phenotype, biliary carcinoma, duodenal perforation and septic abdomen, and choleliths, as well as inflammatory hepatobiliary disease.

Association between hyperlipidemia and calcium oxalate lower urinary tract uroliths in dogs

Background

Metabolic syndrome is associated with formation of calcium oxalate (CaOx) uroliths in humans.

Objectives

To investigate the association between obesity and hyperlipidemia with CaOx lower urinary tract uroliths in client‐owned dogs.

Animals

Dogs with (n = 55, U [uroliths]‐dogs) and without (n = 39, UF [uroliths‐free]‐dogs) CaOx lower urinary tract uroliths.

Methods

Case‐control study. U‐dogs were retrospectively enrolled and compared to UF‐dogs. Body condition score (BCS; 1‐9 scoring scale), serum triglyceride (TG) and total cholesterol (CH) concentrations and glycemia (after >12‐hour food withholding) were recorded in both groups.

Results

On univariate logistic regression, when excluding Miniature Schnauzers, odds of having uroliths increased by a factor of 3.32 (95% CI 1.38‐11.12) for each mmol/L of TG (P = .027), of 39 (95% CI 9.27‐293.22) for each mmol/L of glycemia (P < .0001), and of 2.43 (95% CI 1.45‐4.45) per unit of BCS (P = .002). In multivariable models, the effect of TG was retained when all breeds were included for analysis and odds of having uroliths increased by a factor of 4.34 per mmol/L of TG (95% CI 1.45‐19.99; P = .02).

Conclusions and Clinical Importance

Serum lipid screening in dogs diagnosed with CaOx uroliths might be recommended to improve their medical staging and management.

Cholecystectomy in 23 cats (2005-2021)

OBJECTIVE

To describe the clinical presentation, treatments, and long-term outcomes following cholecystectomy in cats.

STUDY DESIGN

Clinical retrospective study.

ANIMALS

Twenty-three client-owned cats.

METHODS

Medical records of all cats undergoing cholecystectomy between 2005 and 2021 at a single referral hospital were retrospectively reviewed. No cats were excluded. An owner questionnaire assessed long-term outcomes.

RESULTS

Vomiting, jaundice, and abdominal pain were the most common clinical signs; median duration of signs was 4 days (range 1-21). Cholelithiasis was the major indication for cholecystectomy followed by cholecystitis. Intraoperative hypotension and postoperative anemia were commonly encountered. Nine cats required a postoperative blood product transfusion. Cardiopulmonary arrest and death occurred in five cats. Eighteen cats (78.3%) survived to discharge. Long-term follow up (>60 days) was available for 16 cats at a median of 1003 days (range 81-4995). Fifteen cats survived over 6 months with eight cats (44.4%) surviving over 3 years. The most common short-term and long-term postoperative complication was vomiting. Owners assessed postoperative outcome as excellent in all cats and quality of life as excellent or good.

CONCLUSION

The most common indication for cholecystectomy was cholelithiasis. Perioperative complications were commonly encountered. Perioperative mortality rate was 21.7%. Long-term owner evaluation of clinical outcome was considered excellent.

CLINICAL SIGNIFICANCE

Cats undergoing cholecystectomy for non-neoplastic causes can have a favorable prognosis for recovery and quality of life. Concurrent extrahepatic biliary duct obstruction is not a contraindication for cholecystectomy provided that patency of the common bile duct is restored.

Gall bladder ejection fractions in dogs investigated for chronic altered appetite: 14 cases (2015-2017)

OBJECTIVES

To determine if gall bladder dysmotility occurs in dogs investigated for chronic altered appetite and to determine if gall bladder dysmotility warrants further investigation as a contributing factor to altered appetite.

MATERIALS AND METHODS

Case series of dogs investigated for chronic gastrointestinal disease. Gastrointestinal clinical signs were assessed before and after a 6-week hydrolysed protein diet. Gall bladder ejection fractions were determined at the end of the 6-week hydrolysed protein diet as part of an investigation that included a full blood cell count, biochemistry, abdominal X-rays and ultrasound. The gall bladder ejections fraction results of dogs with normal appetite were compared to dogs with general inappetence and dogs with diurnal inappetence in the morning.

RESULTS

In this retrospective case series of 14 dogs, altered appetite was the most frequent and persistent clinical sign associated with chronic gastrointestinal disease. Nine dogs had suboptimal gall bladder function and this occurred in dogs with, and without, gravity-dependent biliary sludge. Gall bladder function and volumes of dogs in this study were comparable to those of dogs with nongravity-dependent gall bladder sludge or gall bladder mucoceles in other studies. There was an observable difference in gall bladder ejection fractions between groups defined by appetite but no statistically significant difference was present. Small sample sizes meant the effect size was large.

CLINICAL SIGNIFICANCE

Gall bladder dysmotility and distension can occur in the absence of gall bladder sludge and mucocoeles in younger dogs. Gall bladder dysmotility requires further investigation as a potential contributing factor to altered appetite in dogs.

Prevalence of subclinical bactibilia in apparently healthy shelter dogs

OBJECTIVES

To determine the prevalence of subclinical bactibilia in apparently healthy shelter dogs and characterise serum liver enzymes activities, hepatobiliary histopathology and bile cytology in apparently healthy dogs with and without bactibilia.

MATERIALS AND METHODS

Healthy, abandoned dogs euthanased for non-medical reasons were prospectively recruited for this cross-sectional study. Whole blood, collected immediately before euthanasia, was submitted for serum liver enzyme activity (alkaline phosphatase, alanine aminotransferase and gamma-glutamyl transferase) analyses. Bile, gall bladder and liver samples were collected aseptically from dogs within 25 minutes of euthanasia. Bile was submitted for bacterial culture and cytology in all dogs. Gall bladder and liver samples were submitted for histopathological examination in bactibilic dogs and nine randomly selected non-bactibilic dogs.

RESULTS

Sixty-five healthy dogs were included in this study. Bactibilia was diagnosed in 10.8% (7/65) of dogs, with 9.2% (6/65) of dogs diagnosed on cytological examination and 4.6% (3/65) on culture. Elevated alanine aminotransferase activities were present in one bactibilic and five non-bactibilic dogs; and elevated gamma-glutamyl transferase activities in one bactibilic and two non-bactibilic dogs. No dogs had elevated alkaline phosphatase activities. Histopathological changes in bactibilic and non-bactibilic dogs included lymphoplasmocellular cholecystitis (7/7 and 9/9), gall bladder oedema (7/7 and 9/9), hepatic vacuolar degeneration (6/7 and 8/9), cholangitis (5/7 and 7/9), hepatic nodular hyperplasia (3/7 and 5/9) and hepatic cholestasis (2/7 and 4/9).

CLINICAL SIGNIFICANCE

This study confirms that subclinical bactibilia occurs in a small number of apparently healthy shelter dogs and that subclinical hepatobiliary histopathological abnormalities can occur in apparently healthy bactibilic and non-bactibilic dogs.

Surgical Management of Feline Extrahepatic Biliary Tract Diseases

Extrahepatic biliary obstruction occurs infrequently in cats. Pathophysiology of biliary obstruction is characterized by cholestasis, obstruction, inflammation, and exudation. Clinical signs and laboratory examination findings are nonspecific. Ultrasonographic examination of the biliary tract aids significantly in diagnosis. The aims of feline biliary surgery are to determine the underlying cause and extent of the obstruction, restore bile flow to the gastrointestinal tract, and prevent bile leakage and subsequent peritonitis. Surgical techniques to restore bile flow and decompress the biliary distension include cholecystostomy tube placement and choledochal stenting, cholecystectomy, choledochotomy, and biliary diversion procedures. Surgical management of extrahepatic biliary obstruction carries a fair to guarded prognosis. Cats undergoing biliary diversion procedures have poorer outcomes than those undergoing nondiversion procedures. Cats with neoplastic involvement have significantly shorter lives than those with inflammatory involvement.

Influence of normograde versus retrograde catheterization of bile ducts in dogs treated for gallbladder mucocele

OBJECTIVE

To determine the influence of normograde (NG) versus retrograde (RG) catheterization of the cystic duct and common bile duct (CBD) in dogs with gallbladder mucoceles (GBM) treated with open cholecystectomy.

STUDY DESIGN

Retrospective study.

ANIMALS

Dogs (n = 117) with GBM.

METHODS

Medical records were reviewed for signalment, history, clinical laboratory and diagnostic imaging findings, details of surgery including catheterization method, complications, and outcome. Long-term follow-up data were obtained by telephone or electronic communication. Relationships between catheterization method and clinical variables and outcome were evaluated.

RESULTS

Dogs catheterized RG were more likely to experience any postoperative complication (p = .0004) including persistence of gastrointestinal signs (p = .0003). Survival to discharge and long-term survival did not differ by group (p = .23 and p = .49). Total bilirubin (TB) decreased by 70.3% after NG catheterization compared to 39.1% after RG catheterization (p = .03) and increased in 14.9% dogs catheterized NG and 38.0% dogs catheterized RG (p = .004). The presence of a diplomate surgeon at surgery resulted in decreased incidences of any perioperative or postoperative complication (p = .003 and p = .05).

CONCLUSION

Retrograde catheterization was associated with more postoperative concerns than NG catheterization, but similar survival times. Surgery should be performed by diplomates experienced in biliary surgery to minimize complications.

CLINICAL SIGNIFICANCE

Although both NG and RG techniques to catheterize the cystic duct and CBD are options for treatment of GBM with low mortality, results of this study provide some evidence to recommend NG over RG catheterization.

Comprehensive Review of Biliary Peritonitis

Biliary peritonitis is a growing concern in the canine patient and a thorough understanding of the disease will lead to better treatment outcomes. This article reviews the human and veterinary literature pertaining to biliary peritonitis including both scientific reviews and original publications. Compared to human medicine, biliary peritonitis can be difficult to diagnose preoperatively. Multiple risk factors exist increasing the likelihood of development of biliary peritonitis. Treatment recommendations center on stabilization, surgical cholecystectomy, and postoperative supportive care. Clinically, further studies on treatment and prevention in veterinary medicine are warranted.

Clinical characteristics and histology of cholecystectomised dogs with nongravity-dependent biliary sludge: 16 cases (2014-2019)

OBJECTIVES

To report the available histology, biochemistry and clinical progression of dogs without classic overt biliary tract signs that underwent cholecystectomy for nongravity-dependent biliary sludge.

MATERIALS AND METHODS

Case series of client-owned dogs for which a cholecystectomy was performed for nongravity-dependent biliary sludge. In six dogs, for which nongravity-dependent biliary sludge filled less than half of gall bladder volume, gall bladder ejection fractions were measured. Available histology, biochemistry, presenting clinical signs and post-surgical clinical progression were reported.

RESULTS

Sixteen dogs were included in this retrospective case series. No dogs met the histological criteria for gall bladder mucocoeles or had histological evidence of primary hepatitis or cholangitis. Biochemistry was normal for 11 dogs. Hypercholesterolaemia was not noted in any dog. Twelve dogs had cholecystitis (11 lymphoplasmacytic, one neutrophilic) and nine dogs had biliary mucosal hyperplasia. Thirteen dogs had enteritis (12 lymphoplasmacytic, one eosinophilic) and nine dogs had reactive hepatitis (eight lymphoplasmacytic, one neutrophilic). All six dogs with nongravity-dependent biliary sludge that filled less than half of gall bladder volume had sub-optimal gall bladder function. Presenting clinical signs, including diurnal inappetence in the morning and exercise intolerance, resolved in 86% (12/14) of dogs after cholecystectomy and clinical improvement was noted in 81% (13/16) of dogs overall.

CLINICAL SIGNIFICANCE

Duodenal inflammation could potentially impact gall bladder dysmotility in dogs with nongravity-dependent biliary sludge. Furthermore, diurnal inappetence in the morning and exercise intolerance could indicate symptomatic gall bladder disease in dogs with NDBS and can potentially precede more obvious systemic clinical signs associated with gall bladder mucocoeles.

Diagnostic and conservative treatment nuances in patients with obstructive jaundice: in the wake of Russian consensus

The research was performed at the Loginov Moscow Clinical Scientific Center. It is based on Russian obstructive jaundice (OJ) consensus results, considered at the 45th annual Central Research Institute of Gastroenterology Scientific session Oncological issues in the gastroenterologist practice (1 March 2019). The article objective is to note the diagnostic and conservative treatment current issues in patients with OJ. The increase in the number of patients with OJ of different etiology provides problem actuality. In a large number of cases, medical treatment is delayed due to inadequate diagnostic and management, while correct patients routing today can be provided regardless of medical institution level. In this article the examination steps and conservative treatment role in patients with biliary obstruction management are presented.

Common bile duct obstruction caused by a helminth in a cat in the UK: ultrasonographic findings, histopathology and outcome

Case summary

An 11-year-old neutered female domestic shorthair cat presented to our hospital with a 5-day history of vomiting, lethargy, anorexia and hyperbilirubinaemia, despite intravenous fluid therapy, gastroprotectants and antibiotic treatment. An abdominal ultrasound revealed a markedly distended common bile duct (diameter 6.2 mm). The cystic duct and intrahepatic bile ducts were also dilated. A linear structure formed by two parallel hyperechoic lines was identified in the common bile duct and could be traced to the duodenal papilla. The cat underwent laparotomy for surgical decompression of the biliary tree. A tubular, brown-coloured structure was retrieved from the common bile duct. Histological examination was consistent with a degenerate helminth. The cat recovered uneventfully from the surgery and its demeanour and appetite improved rapidly over the following days. Liver and gallbladder wall histopathology was consistent with bacterial cholangitis and cholecystitis. Escherichia coli was cultured from both bile and liver parenchyma.

Relevance and novel information

To our knowledge, this is the first reported case of extrahepatic biliary duct obstruction caused by a helminth in a cat in the UK. We hypothesised that the obstruction had been caused by the aberrant migration of an intestinal nematode that became lodged in the duodenal papilla. Ultrasound allowed prompt diagnosis and guided the treatment decision.

Dogs with biliary rupture based on ultrasound findings may have normal total serum bilirubin values

The absence of hyperbilirubinemia can lead to decreased suspicion of biliary rupture in dogs. This delay of suspicion and treatment can result in increased mortality rates. The objective of this retrospective, observational study was to describe ultrasound and serum bilirubin findings in a group of dogs with an ultrasonographic diagnosis of suspected biliary rupture. The records of a single institution were searched over the period of 2007-2019 for cases having ultrasound reports describing suspicion of biliary rupture. Clinical findings for each of the cases were recorded. A total of 35 dogs met inclusion criteria and, of these, 30 dogs had confirmed ruptured biliary tracts. It was found that 40% (12/30) of dogs with confirmed ruptured biliary tracts had a serum bilirubin values within the normal reference range. No statistical difference was found in serum bilirubin values between the ruptured and nonruptured biliary tracts. Leukocytosis and neutrophilia were found to be statistically significant between ruptured and nonruptured biliary tracts. Mucinous material, similar to "white bile" found in human literature, was found within the peritoneal effusion of six dogs with biliary rupture, three of which also lacked bile pigment. Findings from this study indicated that normobilirubinemia may be present in some dogs with biliary rupture, and therefore should not be used as a reason for excluding this differential diagnosis.

Serum 25-hydroxyvitamin D concentrations in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common biliary disorder in dogs. Gallbladder hypokinesia has been proposed to contribute to its formation and progression. The specific cause of gallbladder stasis in dogs with GBM as well as viable treatment options to resolve dysmotility remains unknown. Vitamin D deficiency is one of the many potential causes of gallbladder hypokinesia in humans and repletion results in complete resolution of stasis. Improving our understanding of the relationship between serum vitamin D and GBM could help identify dogs as a model for humans with gallbladder hypokinesia. Furthermore, this relationship could provide insight into the pathogenesis of GBM and support the need for future studies to investigate vitamin D as a novel treatment target. Therefore, goals of this study were i) to determine if serum 25-hydroxyvitamin(OH)D concentrations were decreased in dogs with GBM, ii) if serum 25(OH)D concentrations were different in clinical versus dogs subclinical for GBM, and iii) to determine if serum 25(OH)D concentrations could predict the ultrasonographic type of GBM. Sixty-two dogs (clinical, n = 26; subclinical, n = 36) with GBM and 20 healthy control dogs were included in this prospective observational study. Serum 25(OH)D concentrations were measured with a competitive chemiluminescence immunoassay. Overall, dogs with GBM had lower serum 25(OH)D concentrations than control dogs (P = 0.004). Subsequent subgroup analysis indicated that this difference was only significant in the subclinical group compared to the control dogs (P = 0.008), and serum 25(OH)D concentrations did not significantly differ between dogs clinical for GBM versus subclinical or control dogs, indicating that inflammatory state in clinical dogs was not the major constituent of the observed findings. Decreasing serum 25(OH)D concentrations, but not clinical status, was associated with a more advanced developmental stage of GBM type determined by ultrasonography. Our results indicate that vitamin D has a role in dogs with GBM. Additional studies are needed to assess if reduced vitamin D in dogs with GBM is a cause or effect of their biliary disease and to investigate if vitamin D supplementation could be beneficial for dogs with GBM.

Computed tomographic features of confirmed gallbladder pathology in 34 dogs

Gallbladder pathology is common in dogs, but published studies describing the computed tomographic (CT) appearance of many gallbladder pathologies are currently lacking. This retrospective, multicenter, cases series, descriptive study evaluated the CT features of confirmed gallbladder pathology in 34 dogs. In this subset of dogs, the most common pathologies included cystic mucosal hyperplasia (15/34, 44.1%), gallbladder wall edema (9/34, 26.5%), gallbladder mucocele (8/34, 23.5%), bactibilia (7/34, 20.6%), cholecystitis (6/34, 17.6%), white bile (6/34, 17.6%), and cholelithiasis (4/34, 11.8%). The presence of intraluminal nodules, gallbladder wall thickening, hyperattenuating material (35-100 HU), and mineral attenuating material (>100 HU) were the most common abnormalities detected. However, overlap of each of these findings with a variety of gallbladder pathologies showed that none of the findings were pathognomonic for any of these pathologies. The presence of any of these CT abnormalities should increase the suspicion of gallbladder pathology and prompt further evaluation of the gallbladder for definitive diagnosis.

Evidence-Based Medicine: Ultrasound-Guided Percutaneous Cholecystocentesis in the Cat

Cholangitis is a common cause of hepatobiliary disease in the cat. Feline cholangitis is characterized as neutrophilic (acute or chronic), lymphocytic, or caused by liver flukes. The neutrophilic form is caused by bacterial infection of the biliary system, and identification of the specific bacterial agent guides treatment. Bile is the sample of choice for cytology and bacterial culture in these cases, and percutaneous ultrasound-guided cholecystocentesis is used to obtain that sample. This review covers the literature that provides evidence for safety and usefulness of percutaneous ultrasound-guided cholecystocentesis as part of the diagnostic work-up of cats suspected of having hepatobiliary disease.

[Russian consensus on current issues in the diagnosis and treatment of obstructive jaundice syndrome]

The Russian consensus document on topical issues of the diagnosis and treatment of obstructive jaundice syndrome was prepared by a group of experts in various fields of surgery, endoscopy, interventional radiology, radiological diagnosis and intensive care. The goal of this document is to clarify and consolidate the opinions of national experts on the following issues: timing of diagnosis of obstructive jaundice, features of diagnostic measures, the need and possibility of conservative measures for obstructive jaundice, and strategy of biliary decompression depending on the cause and level of biliary block.

Cholelithiasis in the Dog: Prevalence, Clinical Presentation, and Outcome

Canine cholelithiasis is considered to be an uncommon condition and is frequently cited as being an incidental finding. However, there is a paucity of contemporary literature to support these assertions. The aim of this retrospective cross-sectional study was to report the prevalence, clinical presentation, and long-term follow-up of cholelithiasis in dogs. The electronic database at the Small Animal Hospital, University of Glasgow was searched to identify dogs that were diagnosed with cholelithiasis on ultrasound between 2010 and 2018. Sixty-eight dogs were identified, giving an overall prevalence of cholelithiasis in our hospital of 0.97% (confidence interval 0.76-1.22%). Medical records of 61 dogs were available for review. Cholelithiasis was classified as an incidental finding in 53 (86.9%) dogs, with 8 (13.1%) dogs being classified as symptomatic, having complications of cholelithiasis that included biliary duct obstruction, biliary peritonitis, emphysematous cholecystitis, and acute cholecystitis. Follow-up was available for 39 dogs, with only 3 dogs (7.7%) developing complications attributed to cholelithiasis, including biliary duct obstruction and acute cholecystitis, within the subsequent 2 yr. Cholelithiasis is an uncommon but frequently incidental finding in dogs. Within the follow-up period, few of the dogs with incidental cholelithiasis went on to be become symptomatic.

Feline abdominal ultrasonography: What's normal? What's abnormal? The pancreas

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Ultrasound examination of the pancreas is a vital part of the investigation into feline pancreatic disease.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even for the experienced ultrasonographer, differentiating between incidental findings such as nodular hyperplasia and pathological changes such as neoplasia can be challenging.

AIM

This review, part of an occasional series on feline abdominal ultrasonography, discusses the ultrasonographic examination and appearance of the normal and diseased pancreas. Aimed at general practitioners who wish to improve their knowledge of and confidence in feline abdominal ultrasound, this review is accompanied by high-resolution images and videos available online as supplementary material.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

Suspected Gallbladder Torsion in a Juvenile German Shepherd Dog

An 11 mo old intact female German shepherd dog was presented with a 1 day history of vomiting, abdominal pain, and lethargy. A complete gallbladder torsion with secondary bile leakage was diagnosed during exploratory laparotomy. The dog underwent cholecystectomy at the clearly demarcated border of the viable cystic duct and recovered with no complications. Torsion was possible as a result of the complete absence of normal connective tissue attachments to the hepatic fossa, in human medicine called a wandering gallbladder. No other abnormalities were found on complete abdominal exploration. Very few cases describe torsion of the cystic duct as a cause for extrahepatic biliary disease and secondary bile peritonitis in dogs.

Long-term survival of dogs treated for gallbladder mucocele by cholecystectomy, medical management, or both

BACKGROUND

Gallbladder mucoceles (GBM) typically are treated by cholecystectomy. Medical management rarely has been reported and medical and surgical management have not been compared.

HYPOTHESIS/OBJECTIVES

To compare survival of dogs treated for GBM by medical management or cholecystectomy or both.

ANIMALS

Eighty-nine client-owned dogs diagnosed with GBM that received cholecystectomy or medical treatment or both from 2011 to 2017.

METHODS

Potential cases were identified by searching the medical records database. Data collected included signalment, clinicopathologic results, treatments, and ultrasonographic images and reports. Dogs were grouped according to the treatment received (medical management, surgical treatment, or both) that was chosen at the discretion of the attending veterinarian. Survival analysis was performed and prognostic variables identified and compared between treatment groups.

RESULTS

Of dogs surviving at least 14 days after diagnosis, median survival times were 1802 (95% confidence interval [CI], 855-not reached) days, 1340 (95% CI, 444-1340) days, and 203 (95% CI, 18-525) days, for the surgical, medical, and medical then surgical treatment groups, respectively, and differed significantly (P < .0001). Gallbladder mucocele type (P = .05), serum alkaline phosphatase activity (P = .0001), and serum creatinine (P = .002) and phosphorus (P = .04) concentrations were associated with decreased survival across groups. Suspicion of biliary rupture on abdominal ultrasound (AUS) examination was correlated with increased survival in the surgical group (P = .02).

CONCLUSIONS AND CLINICAL IMPORTANCE

Cholecystectomy for the treatment of GBM results in the best long-term survival in dogs surviving the immediate postoperative period (14 days) compared to medical management. Although medical management is associated with shorter survival compared to surgical treatment, it is a reasonable alternative when surgery cannot be pursued.

Hepatic computed tomography and cholangiography by use of gadoxetic acid in healthy cats

OBJECTIVE

To evaluate 3 doses of gadoxetic acid (Gd-EOB-DPTA) for hepatic CT and cholangiography in cats and to determine optimal timing for hepatobiliary image acquisition and evaluation of the contrast-enhanced hepatobiliary anatomy.

ANIMALS

6 healthy cats.

PROCEDURES

Cats were anesthetized; sequential CT scans were performed 0, 5, 25, 45, 65, and 85 minutes after IV administration of Gd-EOB-DTPA at low (0.0125 mmol/kg), medium (0.1 mmol/kg), and high (0.3 mmol/kg) doses. Hepatobiliary enhancement for each dose was objectively assessed over time and by use of a subjective semiquantitative visual assessment score.

RESULTS

No contrast-related adverse effects were detected. Each increase in dose of contrast medium resulted in a significant increase in HU across the hepatobiliary system. The liver had a significantly higher number of HU at 45 minutes, with homogenous enhancement at all doses of contrast medium. Contrast-enhanced cystic and bile duct HU were significantly higher and maximal at 65 minutes. Contrast-enhanced gallbladder HU did not plateau by 85 minutes. At a high dose of contrast medium, 12 of 60 (20%) biliary tract scores indicated no enhancement, 34 (57%) indicated poor enhancement, and 14 (23%) indicated moderate enhancement. No cat had excellent enhancement of the biliary tract at any dose.

CONCLUSIONS AND CLINICAL RELEVANCE

Gd-EOB-DTPA-enhanced hepatic CT and cholangiography in cats were safely performed and provided good hepatic enhancement but poor to moderate enhancement of the biliary tract. This technique may be useful for assessing the liver parenchyma in cats, but its value for assessing the biliary tract is questionable.

Feline abdominal ultrasonography: what's normal? what's abnormal? The biliary tree

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. The biliary tree encompasses the liver, gall bladder and bile ducts, although only diseases affecting the latter two are discussed here. Diseases of the bile ducts and gall bladder are more common than those of the liver parenchyma and ultrasound plays an important role in their diagnosis.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. In addition, a lack of pathological change does not necessarily rule out disease; for example, absence of gall bladder and/or extrahepatic biliary distension is not sufficient to exclude the possibility of biliary obstruction, and in many cases of cholangitis the liver and biliary tree are unremarkable on ultrasound examination.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

AIM

This review, part of an occasional series on feline abdominal ultrasonography, discusses the appearance of the normal and diseased biliary system. It is aimed at general practitioners who wish to improve their knowledge and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Percutaneous ultrasound-guided cholecystocentesis is also covered. Ultrasound examination of the liver was discussed in an article published in January 2019 and an upcoming article will cover hepatic vascular anomalies.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

Spontaneous cholecystopleural fistula leading to biliothorax and sepsis in a cat

Case summary

A 13-year-old spayed female domestic shorthair cat presented with pleural effusion and suspected triaditis. Intake vitals and leukocytosis were consistent with a diagnosis of systemic inflammatory response syndrome. Biochemical analysis confirmed a pleural fluid-to-serum bile ratio consistent with a diagnosis of biliothorax. Abdominal ultrasound failed to identify a definitive gall bladder but noted a hypoechoic tubular structure ventral to the liver and contacting the diaphragm. Thoracic ultrasound identified a hyperechoic structure contacting the diaphragm at the same location. Thoracoabdominal CT scan identified a fluid-dense tubular structure extending from ventral to the liver, through a diaphragmatic defect and directly communicating with the pleural space, suspected to be an abnormal gall bladder. The cat was humanely euthanized, and post-mortem analysis confirmed a cholecystopleural fistula arising from the gall bladder with multifocal abscesses, mixed inflammatory hepatic infiltrates and small-cell gastrointestinal lymphoma. Culture of the abscess isolated Parabacteroides merdae, meeting the reported feline criteria for sepsis.

Relevance and novel information

To our knowledge, spontaneous cholecystopleural fistula formation leading to biliothorax and sepsis has not been previously reported in the cat. This case highlights a novel sequela of gall bladder disease in this species, and biliothorax should be a differential diagnosis for pleural effusion in cats with evidence of cholecystitis or triaditis.

Reference limits for hepatic bile duct-to-arteriole and bile duct-to-portal tract ratios in healthy cats

OBJECTIVE To establish reference limits for hepatic bile duct-to-arteriole ratio (BD:A) and bile duct-to-portal tract ratio (BD:PT) in healthy cats and assess whether these parameters could be used to support a diagnosis of biliary ductopenia in cats. SAMPLE Hepatic biopsy samples from healthy cats (n = 20) and cats with ductopenia (2). PROCEDURES Hepatic biopsy samples from healthy cats were used to count the number of bile ducts and hepatic arterioles in 20 portal tracts for each cat. Mean BD:A and mean BD:PT for each cat were calculated, and these values were used to determine reference limits for mean BD:A and mean BD:PT. Results of histologic evaluation, including immunohistochemical staining in some instances, were compared for healthy cats versus cats with ductopenia. RESULTS Of the 400 portal tracts from healthy cats, 382 (95.5%) and 396 (99.0%) had BD:A and BD:PT, respectively, ≥ 1.0, with less variability in BD:A. Mean BD:A and BD:PT were markedly lower in both cats with ductopenia, compared with values for healthy cats. However, only mean BD:A for cats with ductopenia was below the reference limit of 0.59. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that systematic evaluation of BD:A, with a lower reference limit of 0.59 to define biliary ductopenia in cats, may be a discrete and easily applied morphometric tool to enhance detection of ductopenia in cats. However, application of this ratio required evaluation of ≥ 20 portal tracts with cross-sectioned portal elements to determine a mean BD:A value.

Feline abdominal ultrasonography: what's normal? what's abnormal? The liver

PRACTICAL RELEVANCE

Abdominal ultrasound plays a vital role in the diagnostic work-up of many cats presenting to general and specialist practitioners. Ultrasound examination of the liver can be key in the diagnosis of diseases such as hepatic lipidosis and hepatic neoplasia.

CLINICAL CHALLENGES

Despite ultrasonography being a commonly used modality, many practitioners are not comfortable performing an ultrasound examination or interpreting the resulting images. Even differentiating between normal variation and pathological changes can be challenging for all but the most experienced. When assessing the liver via ultrasound, a diffuse alteration in liver echogenicity may be difficult to detect unless the change is marked and, although comparisons can be made with the spleen and kidneys, this relies on these organs being normal.

EQUIPMENT

Ultrasound facilities are readily available to most practitioners, although use of ultrasonography as a diagnostic tool is highly dependent on operator experience.

AIM

This review, the first in an occasional series on feline abdominal ultrasonography, discusses ultrasonographic examination of the normal and diseased liver, with focus on the liver parenchyma. It is aimed at general practitioners who wish to improve their knowledge of and confidence in feline abdominal ultrasound and is accompanied by high-resolution images. Ultrasound-guided sampling of the liver is also covered. Future articles will discuss the biliary tree and hepatic vascular anomalies.

EVIDENCE BASE

Information provided in this article is drawn from the published literature and the author's own clinical experience.

Computed tomographic angiography and ultrasonography in the diagnosis and evaluation of acute pancreatitis in dogs

Background

Acute pancreatitis in dogs is an under‐diagnosed disease. Current diagnostic methods are insufficient at identifying sequelae and lack prognostic capability. Computed tomographic angiography (CTA) is accurate for diagnosis and prognostication of pancreatitis in humans.

Objectives

In comparison to ultrasound (US), CTA will (1) better diagnose more severe pancreatitis and sequelae and (2) provide assessment of patient outcome by identification of pancreatic contrast enhancement patterns.

Animals

Twenty‐six client‐owned dogs suspected to have acute pancreatitis.

Methods

US and CTA examinations performed at time of admission were compared to determine the detection of pancreatic changes and sequelae. CTA findings also were compared to outcome indicators for prognosis of dogs with acute pancreatitis. Specific canine pancreatic lipase (cPL) samples were obtained and compared with CTA findings.

Results

Ten of 26 dogs had heterogeneous contrast enhancement of the pancreas. Compared to US, CTA better identified portal vein thrombosis (P = .003). Patients with heterogeneous contrast enhancement had longer hospitalization (P = .01), including hospital stays for >5 days (P = .02), had more relapses, and were more likely to have portal vein thrombosis (P = .002). Patients with heterogeneous contrast enhancement had increased spec cPL (P = .006).

Conclusions and Clinical Importance

In comparison to US, CTA better identified dogs with more severe acute pancreatitis and those with portal vein thrombosis, factors that may predict longer hospitalization and increased risk of relapse. The presence of heterogeneous contrast enhancement and portal vein thrombosis may change therapy for patients with acute pancreatitis.