Feline cholangiohepatitis complex

The Diagnostic Value of Serum Amyloid A and Other Laboratory and Clinical Variables in Cats with Increased Liver Enzyme Activity

Distinguishing inflammatory from non-inflammatory liver disease in cats may impact management. The study aim was to evaluate if certain diagnostic variables, including Serum Amyloid A (SAA), differ (1) between various clinical disease categories (Primary liver disease, Extrahepatic, Trauma and Inconclusive) and (2) between cytological findings of severe hepatic lipidosis and other cytological findings in cats with increased liver enzymes. Medical records from 5042 cats, where SAA had been measured, were reviewed, and 566 cats fulfilled inclusion criteria consisting of increased liver enzymes and available biochemical panel results. SAA was higher in cats diagnosed with trauma compared to other diseases (p = 0.008). Cytology results were available in 85 cats, and cats with severe lipidosis had lower serum SAA concentration (p < 0.0001) and were younger (p < 0.0002) compared to cats with other cytological findings. The study shows that SAA was higher in cats diagnosed with trauma compared to cats with other causes of increased liver enzymes and that SAA may be useful to distinguish cats with cytologic evidence of hepatic lipidosis from cats with other liver pathologies. Serum Amyloid A may be a valuable complement to liver cytology when investigating cats with increased liver enzymes.

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.

Treatment for cholangiohepatitis in cats

Acute bacterial cholangiohepatitis of cats is a common disease associated with the inflammation of bile ducts and liver parenchyma, characterized by development of a pronounced hepatodepressive syndrome (hypoalbuminemia), cytolysis (increase in serum activity of alanine and asparagine transaminase), cholestasis (increase in serum concentration of bilirubin, cholesterol, activity of alkaline phosphatase and gamma-glutamyltranspeptidase), intoxication, dehydration, mesenchymal-inflammatory and pain syndromes. The aim of the research was to study the effectiveness of treatment for acute bacterial cholangiohepatitis in cats with average severity of the pathology course. According to inclusion and exclusion criteria, the study included a cohort of cats (n = 12) with acute bacterial cholangiohepatitis. Clinical, hematological, ultrasonographic, statistical methods of investigation were used in this work. For sick cats with medium severity form of cholangiohepatitis, when administered as a complex therapy the combination of marbofloxacin, metronidazole, ursodeoxycholic acid, cyancobolamine, tocopherol acetate, infusion therapy also had a good therapeutic effect, which was accompanied by improved clinical and laboratory performance. In the blood of cats with cholangiohepatitis, in the background of intensive therapy, there was a significant decrease in white blood cell count, erythrocyte sedimentation rate, and in serum, there was an increase in albumin concentration, reduction of creatinine, aminotransferase activity, alkaline phosphatase, gamma-glutamyltranspeptidase, lipase.

Feline comorbidities: What do we really know about feline triaditis?

PRACTICAL RELEVANCE

Feline triaditis describes concurrent pancreatitis, cholangitis and inflammatory bowel disease (IBD). The reported prevalence is 17-39% in ill referral patients. While the aetiology is poorly understood, it is known to include infectious, autoimmune and physical components. What is not known is whether different organs are affected by different diseases, or the same process; indeed, triaditis may be part of a multiorgan inflammatory disease. Feline gastrointestinal tract anatomy plays its role too. Specifically, the short small intestine, high bacterial load and anatomic feature whereby the pancreatic duct joins the common bile duct before entering the duodenal papilla all increase the risk of bacterial reflux and parenchymal inflammation. Inflammation may also be a sequela of bowel bacterial translocation and systemic bacteraemia.

DIAGNOSTIC CHALLENGES

Cholangitis, pancreatitis and IBD manifest with overlapping, vague and non-specific clinical signs. Cholangitis may be accompanied by increased serum liver enzymes, total bilirubin and bile acid concentrations, and variable ultrasonographic changes. A presumptive diagnosis of pancreatitis is based on increased serum pancreatic lipase immunoreactivity or feline pancreas-specific lipase, and/or abnormal pancreatic changes on ultrasonography, though these tests have low sensitivity. Diagnosis of IBD is challenging without histopathology; ultrasound findings vary from normal to mucosal thickening or loss of layering. Triaditis may cause decreased serum folate or cobalamin (B12) concentrations due to intestinal disease and/or pancreatitis. Triaditis can only be confirmed with histopathology; hence, it remains a presumptive diagnosis in most cases.

EVIDENCE BASE

The literature on feline triaditis, pancreatitis, cholangitis and IBD is reviewed, focusing on histopathology, clinical significance and diagnostic challenges. Current management recommendations are provided. Further studies are needed to understand the complex pathophysiology, and in turn improve diagnosis and treatment.

Triaditis: Truth and Consequences

Clinical findings with triaditis and individual disease components overlap and may include hyporexia, weight loss, lethargy, vomiting, diarrhea, dehydration, icterus, abdominal pain, thickened bowel loops, pyrexia, dyspnea, and shock. A definitive diagnosis of triaditis requires histologic confirmation of inflammation in each organ, but this may not be possible because of financial or patient-related constraints. Evidence-based data indicate that histologic lesions of triaditis are present in 30% to 50% of cats diagnosed with pancreatitis and cholangitis/inflammatory liver disease. Treatment of triaditis is based on the overall health status of the patient and the type and severity of disease in component organs.

Percutaneous cholecystocentesis in cats with suspected hepatobiliary disease

Objectives The objective was to evaluate the safety and diagnostic utility of percutaneous ultrasound-guided cholecystocentesis (PUC) in cats with suspected hepatobiliary disease. Methods Medical records of 83 cats with suspected hepatobiliary disease that underwent PUC were retrospectively reviewed. Results At the time of PUC, at least one additional procedure was performed in 79/83 cats, including hepatic aspiration and/or biopsy (n = 75) and splenic aspiration (n = 18). Complications were noted in 14/83 cases, including increased abdominal fluid (n = 11), needle-tip occlusion (n = 1), failed first attempt to penetrate the gall bladder wall (n = 1) and pneumoperitoneum (n = 1). There were no reports of gall bladder rupture, bile peritonitis or hypotension necessitating treatment with vasopressor medication. Blood products were administered to 7/83 (8%) cats. Seventy-two cats (87%) survived to discharge. Of the cats that were euthanized (9/83) or died (2/83), none were reported as a definitive consequence of PUC. Bacteria were identified cytologically in 10/71 samples (14%); all 10 had a positive aerobic bacterial culture. Bile culture was positive in 11/80 samples (14%). Of the cases with a positive bile culture, cytological description of bacteria corresponded to the organism cultured in fewer than 50% of cases. The most common cytologic diagnosis was hepatic lipidosis (49/66). The most common histopathologic diagnosis was cholangitis (10/21). Conclusions and relevance PUC was safe in this group of cats with suspected hepatobiliary disease. Complications were likely associated with ancillary procedures performed at the time of PUC. Bile analysis yielded an abnormal result in nearly one-third of cats with suspected hepatobiliary disease. Complete agreement between bile cytology and culture was lacking. Further evaluation of the correlation between bile cytology and bile culture is warranted.

Prevalence and Clinicopathological Features of Triaditis in a Prospective Case Series of Symptomatic and Asymptomatic Cats

Background

The term triaditis designates the concurrent presence of idiopathic inflammatory bowel disease (IBD), cholangitis, and pancreatitis in cats.

Hypothesis/Objectives

The histopathology of concurrent, but often subclinical, inflammatory processes in the small intestine, liver, and pancreas of cats is poorly described. We aimed to investigate the frequency of enteritis, cholangitis, pancreatitis, or some combination of these in symptomatic and asymptomatic cats, compare clinicopathological features, and correlate histopathological with laboratory findings.

Animals

Domestic cats (27 symptomatic, 20 asymptomatic, and 8 normal).

Methods

Prospective study. Physical examination, laboratory variables (CBC, serum biochemistry profile, serum thyroxine concentration, serum feline trypsin‐like immunoreactivity [fTLI], feline lipase immunoreactivity [fPLI, as measured by Spec fPL^®], urinalysis, and fecal analysis), imaging, and histopathological examinations were conducted. Feline liver, pancreas, and small intestine were biopsied during laparotomy.

Results

Inflammatory lesions were detected in 47 cats (27 symptomatic, 20 asymptomatic). In total, 20 cats had histopathologic lesions of IBD (13/47, 27.7%), cholangitis (6/47, 12.8%), or pancreatitis (1/47, 2.1%) alone, or inflammation involving >1 organ (27/47, 57.4%). More specifically, 16/47 cats (34.0%) had concurrent lesions of IBD and cholangitis, 3/47 (6.4%) of IBD and pancreatitis, and 8/47 cats (17%) of triaditis. Triaditis was identified only in symptomatic cats (8/27, 29.6%). A mild, positive correlation was detected between the severity (score) of IBD lesions and the number of comorbidities (rho = +0.367, P = .022).

Conclusions and Clinical Importance

Histopathological evidence of IBD or IBD with comorbidities was detected in both symptomatic and asymptomatic cats. The possibility of triaditis should be considered in symptomatic cats with severe IBD.

Evaluation of fluorescence in situ hybridization for the detection of bacteria in feline inflammatory liver disease

The etiopathogenesis of feline inflammatory liver disease (ILD) is unclear. Therefore, we sought to determine the presence and distribution of bacteria within the livers of cats with ILD using eubacterial fluorescence in situ hybridization (FISH). Histopathology from 39 cats with ILD and 19 with histologically normal livers (C) were classified using World Small Animal Veterinary Association guidelines. Hepatic sections were examined by 16 and 23S ribosomal RNA FISH. Antibodies against cytokeratins and factor VIIIa were used to distinguish bile ducts and vascular structures. Histopathologic findings included non-specific reactive hepatitis (12), neutrophilic cholangitis (NC; 12), lymphocytic cholangitis (seven), cholestasis/obstruction (three), probable lymphoma (three) and acute hepatitis (two). Bacteria were observed in 21/39 ILD and 3/19 C (P = 0.0054). In 8/39 ILD and 2/19 C bacteria were restricted to the outer liver capsule (P = 0.29) and may represent contaminants. The prevalence of intrahepatic bacteria was higher (P = 0.008) in ILD (13/31) than C (1/17). Bacteria in ILD were more frequently (P <0.0001) localized to portal vessels, venous sinusoids and parenchyma (12/13) than bile duct (1/13). Bacterial colonization was highest in Escherichia coli-positive NC cats. Concurrent non-hepatic disease, predominantly pancreatic and intestinal (8/10 cats biopsied), was present in all 13 cats with intrahepatic bacteria. Bacterial culture was positive (predominantly E coli and Enterococcus species) in 11/23 (48%) samples, and concurred with FISH in 15/23 cases. The presence of intrahepatic bacteria in 13/31 (41%) cats with ILD suggests a role in etiopathogenesis. The distribution of bacteria within the liver supports the possibility of colonization via either enteric translocation or hematogenous seeding.

Feline cholangitis: a necropsy study of 44 cats (1986-2008)

Forty-four cats diagnosed with moderate to severe cholangitis at necropsy are described. The population comprised 0.86% of all feline necropsies performed during the 22-year study period. Liver specimens were classified as acute neutrophilic cholangitis (ANC), chronic neutrophilic cholangitis (CNC), lymphocytic cholangitis (LC) or chronic cholangitis associated with liver fluke infestation (CC) based on the World Small Animal Veterinary Association (WSAVA) classification scheme. ANC (seven) and CNC (33) comprised the majority of cases. In contrast to previous descriptions, overlap was seen in clinical findings between ANC and CNC subtypes. Results suggest that liver enzyme activity may not predict degree of inflammation. Severity of inflammation varied between liver sections in individual cats, underscoring the need to obtain biopsy samples from multiple sites. Inflammatory bowel disease (50%), pancreatitis (60%), or both (32%) commonly accompanied cholagitis. We conclude that cholangitis is not a common cause of feline mortality. Most cats that succumb to cholangitis have ANC or CNC, and concurrent disease contributes to death in many.

Platynosomum fastosum-induced chronic intrahepatic cholangitis and Spirometra spp. infections in feral cats from Grand Cayman

The occurrence of platynosomiasis and intestinal sparganosis is described in feral cats from Grand Cayman, Cayman Islands. Spirometra spp. was observed within the intestine of 18.18% (10/55) of cats; 1.18% (1/55) of cats demonstrated gross and histological manifestation of parasitism by Platynosomum fastosum, but 14.5% (8/55) of cats had the characteristic pathological manifestations of P. fastosum-induced intrahepatic cholangitis without the concomitant presence of the intraductal trematode. Combined parasitism (Spirometra spp. and P. fastosum) was observed in 9.09% (5/55) of feral cats. Significant pathological findings were only associated with the hepatic fluke, P. fastosum, and were grossly characterized by moderate hepatomegaly with enlarged and dilated bile ducts. Examples of cestodes with morphological features characteristic of Spirometra spp. were observed within the small intestine without any associated pathological lesion. The histopathological evaluation of liver fragments revealed chronic intrahepatic cholangitis with and without the associated intraductal trematode, and was characterized by marked periductal fibrosis, adenomatous proliferation of bile duct epithelium, dilation of intrahepatic bile ducts and portal accumulations of inflammatory cells. The occurrence of the cestode in feral cats coupled with factors that are unique to Grand Cayman makes this island the ideal location for sporadic cases of human sparganosis.

Histopathologic Features, Immunophenotyping, Clonality, and Eubacterial Fluorescence In Situ Hybridization in Cats With Lymphocytic Cholangitis/Cholangiohepatitis

Feline lymphocytic cholangitis is a poorly characterized disease complex with respect to histologic lesions, immunophenotype, and etiopathogenesis. Seventy-eight cases of feline lymphocytic cholangitis ( n = 51) and feline hepatic lymphoma ( n = 27) were reviewed using standardized histopathology, immunophenotyping (B cell and T cell), polymerase chain reaction for T-cell receptor (TCR) gene rearrangement, and fluorescence in situ hybridization (FISH) for eubacteria. Five histopathologic features in cases of lymphocytic cholangitis assisted in its differentiation from hepatic lymphoma: bile duct targeting ( n = 32, 62.7%), ductopenia ( n = 9, 17.6%), peribiliary fibrosis ( n = 37, 72.5%), portal B-cell aggregates ( n = 36, 70.6%), and portal lipogranulomas ( n = 38, 74.5%). The majority of lymphocytic cholangitis cases ( n = 35, 68.6%) were T cell predominant; 15 (29.4%) had an equal mix of B cells and T cells, and 1 (1.9%) had a B cell–predominant infiltrate; 66.6% of hepatic lymphoma cases were T-cell lymphomas. TCR clonality results were unexpected, with 17.1% of cases of lymphocytic cholangitis having clonal or oligoclonal populations and with T-cell lymphomas having variable TCR clonality (63.6% clonal or oligoclonal, 36.3% polyclonal). The majority of lymphocytic cholangitis ( n = 32 of 36, 88.8%) and all hepatic lymphoma cases had no detectable eubacteria using FISH. As demonstrated here, bile duct targeting, ductopenia, peribiliary fibrosis, portal B-cell aggregates, and portal lipogranulomas are lymphocytic cholangitis features that, along with polyclonal TCR (83%), help differentiate it from hepatic lymphoma. No strong evidence was found implicating in situ bacterial colonization as an etiopathogenesis of lymphocytic cholangitis.

Cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases (1994–2003)

OBJECTIVE

To identify factors associated with outcome in cats with extrahepatic biliary tract obstruction (EHBTO) that undergo biliary diversion surgery.

DESIGN

Retrospective case series.

ANIMALS

22 cats.

PROCEDURES

Medical records of cats with surgically confirmed EHBTO that underwent cholecystoenterostomy were reviewed.

RESULTS

Clinical signs and physical examination findings included vomiting, anorexia, icterus, lethargy, weakness, and weight loss. Common clinicopathologic abnormalities included high serum hepatic enzyme activities and serum bilirubin concentration. Abdominal ultrasonography was performed in 21 cats, and all 21 had findings consistent with EHBTO. Eleven of 15 cats in which blood pressure was monitored had intraoperative hypotension. Eighteen cats had anemia following surgery, and 14 cats had persistent hypotension. Extrahepatic biliary tract obstruction was a result of neoplasia in 9 cats and chronic inflammatory disease in 13. Fourteen cats survived long enough to be discharged from the hospital, but only 6 survived > 6 months after surgery, all of which had chronic inflammatory disease. Median survival time for cats with neoplasia (14 days) was significantly shorter than that for cats with inflammatory disease (255 days). No other variable was associated with outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that cats with EHBTO secondary to neoplasia have a poorer prognosis than cats with EHBTO secondary to chronic inflammatory disease. However, the overall prognosis for cats with EHBTO undergoing cholecystoenterostomy must be considered guarded to poor, and the incidence of perioperative complications is high.

Feline cholecystitis and acute neutrophilic cholangitis: clinical findings, bacterial isolates and response to treatment in six cases

Clinicopathological findings from six cats with confirmed cholecystitis or acute neutrophilic cholangitis are presented. Historical findings included lethargy and anorexia or inappetence of up to five days duration. On physical examination all cats were pyrexic and four out of six were jaundiced and had cranial abdominal pain. Bile samples were obtained by cholecystocentesis at exploratory coeliotomy (two cases) or by percutaneous, ultrasound-guided cholecystocentesis (four cases). Gall bladder rupture and bile peritonitis occurred subsequent to ultrasound-guided cholecystocentesis in one case. The most common bacterial isolate was Escherichia coli (four cases); E coli was isolated alone in two cases, in combination with a Streptococcus species (one case) and in combination with a Clostridium species (one case). Streptococcus species alone was isolated from one case, as was Salmonella enterica serovar Typhimurium. The latter is the first reported case of Salmonella-associated cholecystitis in a cat. Concurrent pancreatic or intestinal disease was detected histologically in three cases. All cases were treated with antimicrobials based on in vitro susceptibility results. Treatment was successful in five cases. One cat with concurrent diffuse epitheliotropic intestinal lymphoma was euthanased. Percutaneous ultrasound-guided cholecystocentesis is an effective, minimally-invasive technique enabling identification of bacterial isolates in cats with inflammatory hepatobiliary disease.

Vancomycin for multi-drug resistant Enterococcus faecium cholangiohepatitis in a cat

A 12-year-old, neutered male domestic shorthair cat was evaluated with a life-long history of intermittent, predominantly small bowel diarrhea and a 3 day history of hematochezia. At presentation, the cat had increased liver enzyme activities and an inflammatory leukogram. Histopathology demonstrated inflammatory bowel disease (IBD), cholangiohepatitis and pancreatitis. The cholangiohepatitis was associated with a multi-drug resistant Enterococcus faecium. Gallbladder agenesis was also documented. Treatment with vancomycin was safely instituted for 10 days. Clinical signs resolved, however, cure of the bacterial cholangiohepatitis was not achieved. The risk of vancomycin resistant enterococci (VRE) in human and veterinary medicine is discussed.

Percutaneous ultrasound-guided cholecystocentesis in healthy cats

Percutaneous ultrasound-guided cholecystocentesis (PUC) is a minimally invasive technique for bile collection that is used successfully in human patients with cholecystitis. Its use in veterinary medicine for evaluation of hepatobiliary disorders has been limited because of the perceived unacceptable risk of bile peritonitis. An experimental study was conducted to evaluate the safety and efficacy of PUC, to collect data on bile cytology and bacteriologic culture, and to attempt to isolate Helicobacter spp. from the bile of healthy cats. In fasted and sedated cats, PUC was performed with a 22-gauge 1.5-in. (3.81 cm) needle with an attached 12-mL syringe via a right-sided transhepatic approach (n = 1) or into the fundus of the gallbladder (n = 11) via a right ventral abdominal approach. An attempt was made to completely empty the gallbladder. A small amount of abdominal effusion, consistent with bile or blood, was seen ultrasonographically immediately after aspiration in the 1st cat. Ultrasonographic complications with the 2nd technique were not observed in the remaining 11 cats. Decreased appetite and evidence of mild abdominal pain were detected in 4 cats within 2 days after PUC. The mean neutrophil count increased 2 days after PUC (P < .01) but remained within the reference range. The bile was acellular in 11 of 12 cats, and aerobic, anaerobic, and Helicobacter spp. cultures yielded no growth in 12 of 12 cats. There were no remarkable gross or histologic lesions of abdominal organs at the postmortem examination (8 cats) performed 7-8 days after the procedure. PUC appears to be a safe and technically simple procedure. Further studies are warranted to determine the use and safety of PUC in cats with hepatobiliary diseases.

Animal models of copper-associated liver disease

Recent advances in molecular biology have made possible the identification of genetic defects responsible for Wilson's disease, Indian childhood cirrhosis and copper toxicosis in Long Evans Cinnamon rats, toxic milk mice, and Bedlington terriers. The Wilson's disease gene is localized on human chromosome 13 and codes for ATP7B, a copper transporting P-type ATPase. A genetic defect similar to that of Wilson's disease occurs in Long Evans Cinnamon rats and toxic milk mice. Familial copper storage disorders in Bedlington and West Highland white terriers are associated with early subclinical disease, and copper accumulation with subsequent liver injury culminating in cirrhosis. The canine copper toxicosis locus in Bedlington terriers has been mapped to canine chromosome region CFA 10q26. Recently, a mutated MURR1 gene was discovered in Bedlington terriers affected with the disease. Idiopathic childhood cirrhosis is biochemically similar to copper toxicosis in Bedlington terriers, but clinically much more severe. Both conditions are characterized by the absence of neurologic damage and Kayser-Fleisher rings, and normal ceruloplasmin levels. A recent study added North Ronaldsay sheep to the list of promising animal models to study Indian childhood cirrhosis. Morphologic similarities between the two conditions include periportal to panlobular copper retention and liver changes varying from active hepatitis to panlobular pericellular fibrosis, and cirrhosis. Certain copper-associated disorders, such as chronic active hepatitis in Doberman pinschers and Skye terrier hepatitis are characterized by copper retention secondary to the underlying disease, thus resembling primary biliary cirrhosis in humans. Copper-associated liver disease has increasingly being recognized in Dalmatians. Copper-associated liver diseases in Dalmatians and Long Evans Cinnamom rats share many morphologic features. Fulminant hepatic failure in Dalmatians is characterized by high serum activities of alanine aminotransferase and aspartate aminotransferase, and severe necrosis of centrilobular areas (periacinar, zone 3) hepatocytes. Macrophages and surviving hepatocytes contain copper-positive material. Liver disease associated with periacinar copper accumulation has also been described in Siamese cats. Many questions regarding copper metabolism in mammals, genetic background, pathogenesis and treatment of copper-associated liver diseases remain to be answered. This review describes the similarities between the clinico-pathological features of spontaneous copper-associated diseases in humans and domestic animals.

The surgical treatment of cholelithiasis in cats: a study of nine cases

Nine cats that had surgical treatment for obstructive cholelithiasis were reviewed to evaluate clinical signs, diagnostic test results, and outcome after surgery. Common clinical signs included progressive vomiting (9/9), dehydration (9/9), anorexia (6/9), icterus (5/9), and lethargy (4/9). Five cats had a cholecystectomy performed, one cat had a cholecystotomy, and three cats had a biliary diversion procedure. Four of the cats that had a cholecystectomy had no recurrence of vomiting or anorexia. The majority of cats (7/9) had multiple choleliths, which were radiopaque and most commonly composed of calcium carbonate. Seven cats were diagnosed with cholangiohepatitis, and four of these cats did not need long-term medical therapy. Most cats (7/9) survived long term postsurgery (mean, 21 months; median, 24 months) without additional medical therapy, while the two cats with concurrent hepatic lipidosis died. Cholecystectomy appeared to have low morbidity with good clinical success.

Acquired portosystemic shunting in two cats

Acquired portosystemic shunts (PSS) are a clinical entity distinct from congenital PSS. Their apparent incidence in cats is low, which may reflect the rarity of predisposing hepatic parenchymal disease, such as cirrhosis, in this species. Two cats with acquired PSS associated with primary hepatobiliary disease are described. Relevant findings in acquired PSS are discussed, as are potential reasons for the apparently low incidence in the cat.