Pathogenesis and outcome of extrahepatic biliary obstruction in cats

Ionised hypercalcaemia in a cat with extrahepatic biliary tract obstruction secondary to a bile duct vegetal foreign body

Case summary

A 10-year-old neutered female domestic shorthair cat was presented to our hospital with a 2-day history of anorexia, vomiting and lethargy. The biochemistry panel revealed increased hepatic enzyme activity and serum amyloid A concentration. Haematological values were within reference intervals. An abdominal ultrasound identified a hyperechoic spindle-shaped structure within the common bile duct and a suspected secondary subobstruction, associated with signs of intra- and extrahepatic biliary tract inflammation. During hospitalisation, the cat developed severe and sustained ionised hypercalcaemia. Exploratory surgery was elected as a result of the lack of clinical improvement, despite supportive treatment and suspected retrograde migration of the spindle-shaped structure. Two grass awns were extracted at the junction of an extrahepatic duct and the common bile duct via choledochotomy using intraoperative ultrasound guidance. A stent was then placed in the bile duct to prevent subsequent bile leakage. Histopathology of the liver revealed a moderate neutrophilic and lymphoplasmacytic inflammation with rare bacterial colonies. Escherichia coli was cultured from a bile sample. No specific cause of hypercalcaemia was identified. The cat recovered uneventfully from surgery. Hepatic enzyme activities and hypercalcaemia progressively decreased within a few weeks after surgery and remained within the reference intervals without treatment. Therefore, hypercalcaemia was suspected to be secondary to a foreign body-related granulomatous reaction.

Relevance and novel information

To our knowledge, only one other feline case report of biliary tract obstruction secondary to a biliary foreign body has been described in the literature. This is also the first case reporting the use of intraoperative ultrasound to localise a vegetal foreign body within the biliary tract of a cat. This case is also unique because of the onset of hypercalcaemia suspected to be secondary to a foreign body-related granulomatous reaction.

Combined cholecystotomy, retrograde hydropulsion, and choledochal stenting to treat extrahepatic biliary tract obstruction in 3 cats

Extrahepatic biliary tract obstruction (EHBO) is uncommonly encountered in cats. Surgical treatment aims to decompress the biliary tract and insure bile duct patency. In veterinary medicine, cholecystotomy is not widely used in practice. The objective was to describe the use of cholecystotomy, retrograde hydropulsion of choleliths, and choledochal stenting to remove choleliths from the extrahepatic biliary tract back in the gallbladder. Three adult domestic shorthair cats were presented with anorexia, lethargy, and vomiting. Serum biochemistry revealed hyperbilirubinemia and increased hepatic enzymes. Abdominal ultrasonography showed evidence of EHBO requiring surgical intervention. Choleliths were localized in the proximal and middle portions of the common bile duct (CBD) in the first case, in the distal portion of the CBD and within the major duodenal papilla in the second case, and in the middle and distal portions of the CBD in the third case. Cholecystotomy was followed by retrograde hydropulsion of the choleliths into the gallbladder, after which choledochal stenting was performed. Complications were defined as major when requiring additional medical or surgical treatment, or minor when not. Three major complications were reported. In 2 cases, severe anemia requiring blood transfusion occurred 24 h postoperatively; in 1 case, EHBO recurrence was encountered 41 d postoperatively. All cats were discharged within 4 d following surgery. Two cats were still alive at 12 and 14 mo after surgery, respectively. In the last case, owners refused revision surgery and the cat was euthanized. Key clinical message: Cholecystotomy combined with retrograde hydropulsion of choleliths permitted removal of choleliths and decompression of the biliary tract in 3 cats. Major complications included severe anemia and EHBO recurrence.

Choledochoduodenostomy combined with Billroth II procedure for extrahepatic biliary obstruction and duodenal perforation in a cat

Case summary

A 5-year-old neutered Somali cat presented with a 2-week history of icterus. Diagnostic imaging revealed extrahepatic biliary obstruction (EHBO) due to a common bile duct (CBD) mass. During exploratory laparotomy, a duodenal perforation was discovered incidentally. Choledochoduodenostomy combined with the Billroth II procedure was performed after resection of the CBD mass and the proximal duodenum to treat the EHBO and duodenal perforation. Based on histological and immunohistochemical findings, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation. The cat recovered almost uneventfully and was discharged 11 days after surgery. The cat survived for nearly 100 days without recurrence of EHBO or duodenal perforation; however, intermittent vomiting and weight loss persisted despite supportive medications.

Relevance and novel information

To the best of our knowledge, there is no detailed report on the application of choledochoduodenostomy combined with the Billroth II procedure in cats, as we used to treat the EHBO and duodenal perforation in the present case. As serum gastrin concentrations were elevated on the first day of hospitalisation, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation, which seemed to have caused not only EHBO but also duodenal perforation (Zollinger-Ellison syndrome). The cat survived for almost 100 days without any perioperative complications. However, this combined procedure might be considered as only a salvage option and not as a definitive treatment option in cats requiring simultaneous biliary and gastrointestinal reconstruction because postoperative supportive care could not improve the cat's condition or maintain its quality of life.

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.

Surgical Anatomy of the Gastrointestinal Tract in Cats

In cats, the gastrointestinal tract is one of the regions in which surgical procedures are most frequently performed by veterinary surgeons; therefore, knowledge of the surgical anatomy of the feline gastrointestinal tract is of high importance. The main surgical procedures performed include gastrotomy, gastrectomy, enterotomy, and enterectomy, as well as procedures in the liver and pancreas. There are also anatomical differences between dogs and cats, increasing the need for deep knowledge of the anatomy treated in the different surgical approaches. The aim of the present review is to describe in detail the anatomy of the gastrointestinal tract in cats highlighting the anatomical regions of significant importance in different surgical procedures.

Common bile duct perforation due to choledocholithiasis in a cat with gallbladder agenesis

Case summary

An 8-year-old neutered male domestic shorthair cat was presented for further investigation of anorexia, vomiting and lethargy. Abdominal ultrasonography and contrast-enhanced CT revealed choledocholithiasis with suspected bacterial peritonitis and non-visualisation of the gallbladder. During surgery, the common bile duct was noted to be perforated, and a cholelith was found in the abdominal cavity. No gallbladder was confirmed during surgery. Three months postoperatively, the cat underwent CT cholangiography and absence of the gallbladder with a vestigial duplicated gallbladder was diagnosed.

Relevance and novel information

Gallbladder agenesis is extremely rare in cats, with only one previous report, but several dogs have been diagnosed based on CT cholangiography and laparoscopy. This report describes gallbladder agenesis concurrent with choledocholithiasis in an adult cat and represents the first report of CT cholangiography in a cat with gallbladder agenesis.

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.

Bacterial culture and immunohistochemical detection of bacteria and endotoxin in cats with suppurative cholangitis-cholangiohepatitis syndrome

OBJECTIVE

To characterize the frequency and type of bacterial infection by culture- and immunohistochemical (IHC)-based methods and determine the impact of infection on clinical features and survival time in cats with suppurative cholangitis-cholangiohepatitis syndrome (S-CCHS).

ANIMALS

168 client-owned cats with S-CCHS (cases).

PROCEDURES

Clinical features, bacterial culture results, culture-inoculate sources, and survival details were recorded. Cases were subcategorized by comorbidity (extrahepatic bile duct obstruction, cholelithiasis, cholecystitis, ductal plate malformation, biopsy-confirmed inflammatory bowel disease, and biopsy-confirmed pancreatitis) or treatment by cholecystectomy or cholecystoenterostomy. Culture results, bacterial isolates, Gram-stain characteristics, and IHC staining were compared among comorbidities. Lipoteichoic acid IHC staining detected gram-positive bacterial cell wall components, and toll-like receptor expression IHC reflected pathologic endotoxin (gram-negative bacteria) exposure.

RESULTS

Clinical features were similar among cases except for more frequent abdominal pain and lethargy in cats with positive culture results and pyrexia, abdominal pain, and hepatomegaly for cats with polymicrobial infections. Bacteria were cultured in 93 of 135 (69%) cats, with common isolates including Enterococcus spp and Escherichia coli. IHC staining was positive in 142 of 151 (94%) cats (lipoteichoic acid, 107/142 [75%]; toll-like receptor 4, 99/142 [70%]). With in-parallel interpretation of culture and IHC-based bacterial detection, 154 of 166 (93%) cats had bacterial infections (gram-positive, 118/154 [77%]; gram-negative, 111/154 [72%]; polymicrobial, 79/154 [51%]). Greater frequency of bacterial isolation occurred with combined tissue, bile, and crushed cholelith inoculates. Infection and gram-positive bacterial isolates were associated with significantly shorter long-term survival times.

CLINICAL RELEVANCE

S-CCHS was associated with bacterial infection, pathologic endotoxin exposure, and frequent polymicrobial infection in cats. Combined tissue inoculates improved culture detection of associated bacteria.

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.

Clinical features, concurrent disorders, and survival time in cats with suppurative cholangitis-cholangiohepatitis syndrome

OBJECTIVE

To characterize clinical features, comorbidities, frequency of bacterial isolation, and survival time in cats with suppurative cholangitis-cholangiohepatitis syndrome (S-CCHS).

ANIMALS

168 client-owned cats with S-CCHS.

PROCEDURES

Data were prospectively (1980 to 2019) collected regarding clinical features, comorbidities, bacterial infection, illness duration, and treatments. Variables were evaluated for associations with survival time.

RESULTS

Median age of cats was 10.0 years, with no breed or sex predilection observed. Common clinical features included hyporexia (82%), hyperbilirubinemia (80%), lethargy (80%), vomiting (80%), jaundice (67%), weight loss (54%), and hypoalbuminemia (50%). Comorbidities included extrahepatic bile duct obstruction (53%), cholelithiasis (42%), cholecystitis (40%), and ductal plate malformation (44%) as well as biopsy-confirmed inflammatory bowel disease (60/68 [88%]) and pancreatitis (41/44 [93%]). Bacterial cultures were commonly positive (69%) despite prebiopsy antimicrobial administration in most cats. Of surgically confirmed choleliths, diagnostic imaging identified only 58%. Among 55 cats with "idiopathic pancreatitis," 28 (51%) were documented to have transiting choleliths, and 20 had pancreatic biopsies confirming pancreatitis. Cholelithiasis (with or without bile duct obstruction) and cholecystectomy were associated with survival advantages. Survival disadvantages were found for leukocytosis, ≥ 2-fold increased alkaline phosphatase, and hyperbilirubinemia. Cholecystoenterostomy had no survival impact. Cats with ductal plate malformations were significantly younger at diagnosis and death than other cats. Chronic treatments with antimicrobials, S-adenosylmethionine, and ursodeoxycholic acid were common postbiopsy.

CLINICAL RELEVANCE

S-CCHS in cats was associated with bacterial infection and various comorbidities and may be confused with pancreatitis. Surgically correctable morbidities (ie, cholecystitis, cholecystocholelithiasis) and cholecystectomy provided a significant survival advantage.

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.

Percutaneous-endoscopic rendezvous cholangiography with biliary stent placement in a dog with extra-hepatic biliary duct obstruction

A middle-aged male springer spaniel was presented for investigation of acute vomiting, lethargy and icterus. Marked distension of the gall bladder and common bile duct was evident at ultrasound due to obstruction by mineralised intraluminal material. After 48 hours of hospitalisation with intravenous fluid therapy, analgesia and antimicrobial therapy, intervention was deemed necessary to relieve the obstruction. A percutaneous-endoscopic rendezvous approach was used to achieve placement of a pigtail stent into the distal common bile duct, successfully relieving the obstruction. Serial biochemistry measurements postprocedure confirmed marked improvements in serum bilirubin. The patient remains clinically well 24 months postprocedure, and all hepatic enzyme activities have normalised. Based on the literature search performed, this is the first successful application of this technique in the management of canine extrahepatic biliary duct obstruction.

Choledochal stenting for treatment of extrahepatic biliary obstruction in cats

Background

Limited information currently exists regarding the clinical progression and outcomes of cats that undergo choledochal stenting as a treatment for extrahepatic biliary obstruction (EHBO).

Hypothesis/Objectives

Describe clinical characteristics, indications for choledochal stent placement, procedure, and outcomes in a cohort of cats undergoing choledochal stenting and evaluate risk factors associated with survival as well as recurrence of EHBO in affected cats.

Animals

Twenty‐three client‐owned cats undergoing choledochal stent placement.

Methods

Retrospective study. Medical records from 6 academic institutions were reviewed, and data were extracted and analyzed statistically.

Results

Median age of cats was 10.1 years (range, 2‐16), and all cats had at least 2 clinical signs. Most common clinical signs were vomiting in 20/22 (90.9%), inappetence in 19/22 (86.4%), and lethargy in 19/23 (82.6%). Procedural complications were uncommon and rarely related to the stenting procedure. Clinical signs improved postoperatively in 15/20 (75.0%) cats and serum total bilirubin concentration decreased postoperatively in 13/19 (68.4%) cats. Eighteen (78.3%) cats survived to discharge. Recurrence of EHBO was documented in 7/18 (38.9%) cats that survived to discharge. Cholelithiasis was associated with recurrence of EHBO. Median survival time for cats that survived to discharge was 931 days (range, 19‐3034). Absence of peritoneal effusion was associated with survival to discharge.

Conclusions and Clinical Importance

Choledochal stenting was an effective treatment modality in cats with EHBO with few procedural complications and potential for prolonged survival, but substantial risk for recurrence of EHBO was identified.

Gallbladder and Liver Lobe Torsion in a Young Cat Presented with Hemoabdomen

An 11 mo old domestic shorthair presented with acute lethargy. The cat was hypothermic and bradycardic and had pale pink mucous membranes, poor pulses, and a distended abdomen. Point-of-care ultrasound identified significant abdominal effusion, which was diagnosed to be a hemoabdomen. Bloodwork revealed hyperlactatemia, regenerative anemia, neutrophilia, hypoproteinemia, hypoalbuminemia, and increased alanine aminotransferase. The cat received an allotransfusion and a subsequent canine xenotransfusion and received further supportive therapy. After stabilization, abdominal ultrasonography diagnosed a gallbladder and liver lobe torsion with hemoabdomen. Exploratory laparotomy confirmed the torsion of the right medial and quadrate hepatic lobes together with the gallbladder. Cholecystectomy and lobectomy of the affected lobes were performed using a surgical stapler. The cat was discharged after 4 days. Histopathology confirmed hemorrhagic infarction of the liver lobes and gallbladder, consistent with the described torsion, and the hepatic pseudocyst. It also demonstrated a mucocele in the gallbladder. One month postoperatively, the cat had totally recovered. Hepatic lobe torsion without neoplasia is a rare disease in cats, with variable clinical signs. Gallbladder torsion is a hitherto unreported condition in cats. This is the first report of gallbladder and liver lobe torsion with secondary hemoabdomen in a cat, successfully treated by one-stage surgery.

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.

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.

Ultrasonographic evaluation of cholecystoduodenostomy sites in six cats

CASE SERIES SUMMARY

This case series describes the postoperative ultrasonographic findings in six cats that underwent a cholecystoduodenostomy as treatment for extrahepatic biliary obstruction. The surgery site was identified in all six cats, most often within the right cranial abdomen as a thick-walled gall bladder, with a broad-based connection to the descending duodenum. Postoperatively, the biliary tree often remained distended, similar to its preoperative appearance. Recurrent extrahepatic biliary obstruction was suspected in three cats with worsening hyperbilirubinemia. Common bile duct distension was progressive in one of these cats and unchanged in another, but improved in the third. Intrahepatic bile duct distension resolved in one cat following surgery but reappeared with suspected recurrent biliary obstruction. In two cats, progressive echogenic biliary contents were associated with locally aggressive cholangiocarcinoma. Our findings suggest that in cats with cholecystoduodenostomy and progressive increases in hyperbilirubinemia following surgery, progressive or recurrent biliary distension and/or progressive echogenic biliary contents should prompt further investigation.

RELEVANCE AND NOVEL INFORMATION

Biliary diversion surgery in cats is associated with high morbidity and mortality. The ultrasonographic appearance of a postoperative cholecystoduodenostomy site has not been described, making differentiation of the expected appearance from postoperative abnormalities difficult. The goal of this study was to determine the expected ultrasonographic appearance, in order to assist in managing cats with recurrent, persistent or worsening clinical signs and biochemical abnormalities following surgery.

Thromboelastography in cats with cholestatic liver disease

OBJECTIVES

While thromboelastography (TEG) has helped define a complex state of hemostasis in dogs and humans with hepatobiliary disease, it has not been explored in cats with cholestatic liver disease (CLD). The objective of this study was to describe TEG parameters in cats with CLD and to compare these parameters with conventional plasma-based coagulation tests, white blood cell (WBC) count and biochemical indicators of liver disease grade and severity.

METHODS

Eighteen cats with CLD, defined by a serum bilirubin ⩾3 mg/dl and a greater than two-fold increase in serum alanine aminotransferase (ALT) and/or alkaline phosphatase (ALP) activity, were prospectively enrolled. All cats received vitamin K1 subcutaneously for 24-36 h prior to acquisition of blood for kaolin-activated TEG analysis, prothrombin time (PT) and activated partial thromboplastin time (aPTT). Patient total solids, packed cell volume, platelet count, WBC count, and serum liver enzymes and bilirubin were extracted from the medical record and correlated with coagulation test results.

RESULTS

TEG global clot strength (TEG G) values defined 9/18 (50%), 5/18 (28%) and 4/18 (22%) cats as hypercoagulable, normocoagulable or hypocoagulable, respectively. TEG G was significantly negatively correlated with PT, aPTT and serum ALP activity and positively correlated with total solids. Five cats (5/18, 28%) were hyperfibrinolytic with clot lysis at 60 mins (LY 60) >15.3%. LY 60 was significantly positively correlated with PT.

CONCLUSIONS AND RELEVANCE

By TEG analysis, cholestatic cats replete with vitamin K1 display a variety of coagulation profiles. Indications of synthetic failure (prolonged PT and aPTT) were associated with hypocoagulable and hyperfibrinolytic TEG parameters. High disease activity (serum ALP) was associated with a hypocoagulable state.

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.

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.

Feline pancreatic ducts are consistently identified on CT and more likely to be dilated in the body of pancreas in cats with elevated feline pancreatic lipase immunoreactivity

Feline pancreatitis is a challenge to diagnose and no previously published study has described the CT characteristics of the pancreatic duct (PD) in cats. The current prospective analytical study was performed to identify and describe the CT characteristics of the PD in normal cats and to compare that to those cats with an elevated feline pancreatic lipase immunoreactivity (fPLI). Contrast-enhanced CT was performed in 16 normal cats and 13 cats with an elevated fPLI. Two ACVR-certified radiologists blinded to the fPLI status assessed whether or not the PD could be identified, contrast phase during which the PD was most conspicuous, and PD shape in the body, right and left lobes. A second-year radiology resident blinded to the fPLI status measured maximum PD diameter and PD:parenchyma. The PD was identified in 84 of 87 pancreatic segments, which was most conspicuous in the portal phase in 28 of 29 cats. The PD shape was tubular (48/84), tapered (34/84), or beaded (2/84) with no significant difference (P = 1.0 to .1615) between groups. Mean maximal PD diameters of normal cats were 1.5-1.7 mm, which was significantly larger in the body of the pancreas in cats with an elevated fPLI (2.4 mm, P = .0313). Mean PD:parenchyma was not significantly different between groups (P = .2001 to .949). In conclusion, the feline PD can be consistently identified on CT, for which the portal phase is preferred. Cats with an elevated fPLI are more likely to exhibit dilation of the PD in the body of the pancreas on CT.

Common bile duct obstruction palliated with common bile duct re-implantation (choledochoduodenostomy) in a cat

A cat was presented with complete biliary obstruction at the level of the distal common bile duct (CBD), with loss of normal architecture. The area was excised and submitted for histopathology. Concurrent cholecystitis and gall bladder necrosis necessitated cholecystectomy. The proximal CBD was preserved and re-implanted adjacent to the original duodenal papilla. The cat recovered and remained asymptomatic for 6 months. At clinical relapse a carcinoma of suspected biliary origin was confirmed, and the cat was euthanized. In situations in which the CBD lumen cannot be re-established, the pathology is limited to the distal CBD, and the gall bladder is not available for cholecystoenterostomy, CBD re-implantation may be an option to salvage and retain a functional biliary tree.

Choledochotomy for Obstructive Choledocholithiasis in Two Dogs

Two geriatric (> 9 years old) dogs presented for vomiting, lethargy, and anorexia. Obstructive choledocholithiasis was diagnosed based on analysis of a serum biochemical analysis and abdominal radiographs and ultrasonography. In both dogs, choledocholiths were removed from the common bile duct via a choledochotomy without a cholecystectomy, and survival without recurrence occurred in both dogs for more than 1 year.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

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.

Successful vascularized jejunal patch graft to treat severe orad duodenal injury secondary to foreign body obstruction in a dog

OBJECTIVE

To report the surgical treatment and outcome of an adult dog with a duodenal perforation treated with a vascularized jejunal patch graft.

STUDY DESIGN

Case report.

ANIMAL

A 1-year-old castrated male boxer dog.

METHODS

Damage to a duodenal segment containing the major and minor papillae was repaired with a vascularized jejunal graft. A segment of healthy jejunum was mobilized maintaining the jejunal vessels, and a donor site anastomosis was performed. The vascularized jejunal graft was incised on the antimesenteric border creating a rectangular segment, which was trimmed and sutured to the duodenal recipient site as a patch graft to repair the defect.

RESULTS

The dog recovered well without major complications. Within 2 weeks, appetite and bowel movements were normal, with no episodes of vomiting. Infrequent regurgitation resolved without medical therapy.

CONCLUSION

A vascularized jejunal patch graft is a feasible option for successful surgical repair of duodenal injury in the dog.

CLINICAL SIGNIFICANCE

This report describes a novel surgical repair technique for treatment of gastrointestinal injuries.

Resolution of a Biliary Obstruction Caused by Platynosomum fastosum in a Feline by a Modified Cholecystoduodenostomy Approach – Case Report

Diseases of the biliary tract are the most common feline hepatic disorders. Cholangitis is the term used to describe inflammation of the biliary tract in felines and can be associated with parasites. Affected animals must undergo clinical or surgical treatment, or a combination of both. In this paper we presented a 10-year-old male, mongrel feline with an obstruction of the biliary tract caused by a rare infection of Platynosomum fastosum.

Ultrasonographic and clinicopathologic features of segmental dilatations of the common bile duct in four cats

CASE SERIES SUMMARY

This case series documents ultrasonographic and clinicopathologic features of four cats with marked segmental dilatations of the common bile duct (CBD). All cats had additional ultrasonographic changes to the hepatobiliary system, including hepatomegaly, tubular to saccular intra/extrahepatic biliary duct dilatation and biliary debris accumulation. Based on all available data the presence of extrahepatic biliary duct obstruction (EHBDO) was ruled out in 3/4 cases and was equivocal in one case. One cat underwent re-routing surgery to address the CBD dilatation after multiple recurrent infections, one cat was euthanized and had a post-mortem examination and two cats were medically managed with antibiotics, liver protectants, gastroprotectants and cholerectics.

RELEVANCE AND NOVEL INFORMATION

The ultrasonographic features of the CBD in this population of cats were supportive of choledochal cysts (CCs). The maximal diameter of the CBD dilatations exceeded 5 mm in all cases, a sign that has been previously reported to be consistent with EHBDO. In our study, dilatations were segmental rather than diffuse. Given the high morbidity and mortality associated with hepatobiliary surgery in cats, segmental dilatation of the CBD should not prompt emergency surgery. Some cats may respond to medical management. Careful planning for cyst resection was beneficial in one cat. Evaluation of CC morphology (eg, size, location, concurrent intrahepatic anomalies) may assist in selecting cats that could benefit from surgical intervention.

Ultrasonographic and clinicopathologic features of segmental dilatations of the common bile duct in four cats

Case series summary

This case series documents ultrasonographic and clinicopathologic features of four cats with marked segmental dilatations of the common bile duct (CBD). All cats had additional ultrasonographic changes to the hepatobiliary system, including hepatomegaly, tubular to saccular intra/extrahepatic biliary duct dilatation and biliary debris accumulation. Based on all available data the presence of extrahepatic biliary duct obstruction (EHBDO) was ruled out in 3/4 cases and was equivocal in one case. One cat underwent re-routing surgery to address the CBD dilatation after multiple recurrent infections, one cat was euthanized and had a post-mortem examination and two cats were medically managed with antibiotics, liver protectants, gastroprotectants and cholerectics.

Relevance and novel information

The ultrasonographic features of the CBD in this population of cats were supportive of choledochal cysts (CCs). The maximal diameter of the CBD dilatations exceeded 5 mm in all cases, a sign that has been previously reported to be consistent with EHBDO. In our study, dilatations were segmental rather than diffuse. Given the high morbidity and mortality associated with hepatobiliary surgery in cats, segmental dilatation of the CBD should not prompt emergency surgery. Some cats may respond to medical management. Careful planning for cyst resection was beneficial in one cat. Evaluation of CC morphology (eg, size, location, concurrent intrahepatic anomalies) may assist in selecting cats that could benefit from surgical intervention.

Life-threatening perianaesthetic complications in five cats undergoing biliary tract surgery: case series and literature review

Case series summary The aim of this case series was to describe the intra- and early postanaesthetic complications occurring in five cats undergoing major surgeries involving the gallbladder and the biliary tree. The five cases of this series were admitted to the Queen Mother Hospital for Animals between June and December 2015, and were all overseen by the same senior anaesthesist. Pre-existing pancreatitis was a common finding. Observed life-threatening events were persistent, unresponsive hypotension in the absence of major blood loss, which occurred mainly during surgical manipulation of the biliary tract, and postoperative renal failure. Relevance and novel information Biliary surgery carries the potential for life-threatening complications in cats. The pathogenesis of such morbidities is likely to be multifactorial. The perianaesthetic use of haemoglobin-based oxygen-carrying solution may be considered as an alternative treatment option when hypotension is unresponsive to fluids and traditional positive inotropes and vasopressors.

Adrenal function in cats with cholestatic liver disease

Cats with cholestatic liver disease experience significant morbidity and mortality when they undergo invasive procedures under anesthesia. Although inadequate adrenal response might account for these outcomes, adrenal function in cats with cholestatic liver disease has not been documented, to our knowledge. The goal of our study was to describe adrenal function in these cats. Twenty-seven cats with a serum bilirubin >230 µmol/L (3 mg/dL) and serum alanine aminotransferase >2 times the upper limit of normal had pre– and 60-min post–adrenocorticotropic hormone (ACTH) cortisol analysis after administration of 5 µg/kg cosyntropin intravenously. The change in cortisol concentrations (delta cortisol) was calculated. Pre- and post-ACTH cortisol concentrations were compared to reference values. Pre-ACTH, post-ACTH, and delta cortisol values were compared between cats surviving to discharge or for 30 d postdischarge. Mean pre-ACTH cortisol levels (205 ± 113 nmol/L [7.4 ± 4.2 µg/dL]) and post-ACTH cortisol levels (440 ± 113 nmol/L [15.9 ± 4.1 g/dL]) in cholestatic cats were significantly greater than reference values in clinically normal cats. There was no association of pre- or post-ACTH cortisol with survival. Cats with a delta cortisol <179 nmol/L (6.5 µg/dL) were more likely to be non-survivors at 30 d post-discharge ( p = 0.037) than cats with delta cortisol >179 nmol/L (6.5 µg/dL). Results indicate that cats with cholestasis have high basal and ACTH-stimulated cortisol values. A delta cortisol <179 nmol/L (6.5 µg/dL) defines a population of cats that have decreased 30-d survival.

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.

Clinical Characteristics of Hepatocellular Carcinoma in 19 cats from a Single Institution (1980-2013)

Clinical features of feline hepatocellular carcinoma (HCA) have been poorly characterized. In this retrospective study, we describe the signalment, clinical features, clinicopathologic parameters, imaging characteristics, hepatic mass size and lobe distribution, concurrent disorders, and survival in 19 cats with HCA. HCA is a rare neoplasm in elderly cats often associated with weight loss, hyporexia, and increased hepatic transaminase activities. Concurrent disorders (e.g., hyperthyroidism, inflammatory bowel disease, cholangiohepatitis, copper-associated hepatopathy) often confounded interpretation of clinical and clinicopathologic findings; 42% of HCA were incidentally identified. Although an abdominal mass was palpated in only 21% of cats, many cats had masses identified on ultrasonographic imaging with 47% having lesions >4 cm. Tumors were nearly equally distributed between right and left liver lobes, and two cats had HCA in multiple liver lobes. Median survival of eight cats diagnosed antemortem was 1.7 (0.6 to 6.5) yr. Median survival of six cats undergoing HCA surgical resection was 2.4 (1.0 to 6.5) yr with two cats still alive at time of manuscript submission. Following surgical resection, one cat treated with carboplatin survived 4 yr. Two cats with HCA diagnosed antemortem without surgical resection survived for 0.6 and 1 yr.

Extrahepatic biliary duct obstruction as a result of involuntary transcavitary implantation of hair in a cat

Case summary

A 4-year-old male neutered domestic shorthair cat was referred for investigation of jaundice. The cat had a recent history of a skin laceration repair following trauma. Sequential serum biochemistry demonstrated increasing plasma bilirubin concentrations; abdominal ultrasonography revealed ongoing pancreatitis and apparent extrahepatic obstruction of the common bile duct. Exploratory laparotomy identified constriction of the common bile duct with foreign material (cat hair). The constricting band of hair was removed surgically; cholecystoduodenostomy was performed. Postsurgical quality of life is excellent with chronic treatment of tylosin, omeprazole and ursodeoxycholic acid.

Relevance and novel information

To our knowledge, this is the first reported case of extrahepatic biliary duct obstruction resulting from the intra-abdominal migration of a foreign body, in this case, hair shafts. The mechanism by which this occurred was likely a combination of physical constriction by the hair shafts and subsequent foreign body reaction surrounding this. This should be included in the differential diagnosis of a cat with jaundice.

Diagnosis of pancreatitis in dogs and cats

Pancreatitis is the most common disorder of the exocrine pancreas in both dogs and cats. Ante-mortem diagnosis of canine and feline pancreatitis can be challenging. The clinical picture of dogs and cats with pancreatitis varies greatly (from very mild to severe or even fatal) and is characterised by non-specific findings. Complete blood count, serum biochemistry profile and urinalysis should always be performed in dogs and cats suspected of having pancreatitis, although findings are not-specific for pancreatitis. Serum amylase and lipase activities and trypsin-like immunoreactivity (TLI) concentrations have no or only limited clinical value for the diagnosis of pancreatitis in either dogs or cats. Conversely, serum pancreatic lipase immunoreactivity (PLI) concentration is currently considered to be the clinicopathological test of choice for the diagnosis of canine and feline pancreatitis. Abdominal radiography is a useful diagnostic tool for the exclusion of other diseases that may cause similar clinical signs to those of pancreatitis. Abdominal ultrasonography can be very useful for the diagnosis of pancreatitis, but this depends largely on the clinician's experience. Histopathological examination of the pancreas is considered the gold standard for the diagnosis and classification of pancreatitis, but it is not without limitations. In clinical practice, a combination of careful evaluation of the animal's history, serum PLI concentration and abdominal ultrasonography, together with pancreatic cytology or histopathology when indicated or possible, is considered to be the most practical and reliable means for an accurate diagnosis or exclusion of pancreatitis compared with other diagnostic modalities.

Pancreatitis in cats: is it acute, is it chronic, is it significant?

PRACTICAL RELEVANCE

Pancreatitis is a frequent finding in cats, the chronic form being more common than the acute form. Despite the large number of diseases or conditions that may be associated with feline pancreatitis, in most cases no cause is diagnosed and the pancreatitis is said to be idiopathic. The chronic form can be mild and asymptomatic, and has a high prevalence in apparently healthy cats. This has generated debate concerning the clinical significance of chronic feline pancreatitis. However, several reports have demonstrated the severity of clinical signs in certain forms of acute feline pancreatitis, while other studies have reported a strong association between chronic pancreatitis and the development of comorbidities such as hepatic lipidosis, diabetes mellitus, inflammatory bowel disease or exocrine pancreatic insufficiency. This suggests that feline pancreatitis should not be overlooked.

CLINICAL CHALLENGES

Diagnosis of feline pancreatitis is complicated by the non-specific clinical signs and poor diagnostic value of basic biochemistry and haematology or imaging techniques. Development of a feline-specific pancreatic lipase immunoassay has improved our diagnostic ability in the past decade, but may have more limited application for mild and chronic forms of pancreatitis. Moreover, histopathology (the 'gold standard' diagnostic test) can be associated with false-negative results due to multifocal distribution of lesions or mild forms of the disease. With respect to treatment, it is important to take into account the idiosyncrasies of the feline species when considering medical therapies.

EVIDENCE BASE

This article reviews the literature on feline pancreatitis, focusing on the different forms and their relative clinical significance, while explaining difficulties inherent in the diagnosis of this disease. An overview of current recommendations for the management of cats with pancreatitis is also provided.

Gall bladder rupture associated with cholecystitis in a domestic ferret (Mustela putorius)

A six‐year‐old neutered female albino ferret was presented with an acute episode of lethargy and anorexia. Clinical examination revealed marked cranial abdominal pain. A severe neutrophilic leukocytosis was present. Abdominal ultrasound was consistent with a diffuse peritonitis and severe bile duct inflammation. Cytology of the abdominal effusion revealed bile peritonitis. An exploratory laparotomy was performed and the gall bladder appeared inflamed with multiple perforations. A cholecystectomy was performed. The ferret recovered without complication. Bacteriological culture of the bile and gall bladder yielded a pure growth of Pseudomonas aeruginosa. Histopathological analysis of the gall bladder and liver was consistent with a marked cholecystitis and cholangiohepatitis. On the basis of sensitivity testing, the ferret was treated with marbofloxacin for one month. No complications or reoccurrence were seen up to 1 year after the diagnosis. To the author's knowledge, this is the first report of bile peritonitis secondary to gall bladder rupture in a ferret.

Mechanisms, causes, investigation and management of vomiting disorders in cats: a literature review

Vomiting is a common presenting complaint in feline practice. This article differs from previous reviews in that it is an evidence-based review of the mechanisms, causes, investigation and management of vomiting in the domestic cat. Published evidence was reviewed, and then used to make recommendations for clinical assessment, diagnosis, antiemetic drug treatment, dietary management and monitoring of cats presenting with vomiting. The strength of the evidence on which recommendations are made (and areas where evidence is lacking for cats) has been highlighted throughout.