Pancreatitis and triaditis in cats: causes and treatment

Successful treatment of feline pancreatolithiasis associated with an ascending Providencia rettgeri infection using a novel surgical technique

A 12-year-old female spayed Domestic Shorthair cat presented with a 4-day history of lethargy, inappetence and vomiting. Physical findings included a grade 2/6 heart murmur and cranial abdominal pain on palpation. Serum biochemistry revealed elevated total bilirubin and liver enzymes activities. Abdominal ultrasound revealed multiple pancreatoliths, cholelithiasis and dilation of the pancreatic duct. During exploratory laparotomy, catheterisation of the pancreatic duct with retrograde and orthograde flushing to remove the pancreatoliths was performed via a distal enterotomy and proximal left apical partial pancreatectomy respectively. Catheterisation and flushing of the common bile duct were performed to confirm patency prior to cholecystectomy. Bacterial culture of pancreatoliths, pancreatic tissue and bile grew a heavy, pure growth of Providencia rettgeri. Fluorescent immunostaining histopathology revealed clusters of rod-shaped bacteria within the pancreatic parenchyma and gall bladder mucosa. The cat received pradofloxacin for two weeks. She made a complete recovery and remained well at a six-month follow-up.

Short colon syndrome in cats

BACKGROUND

Shortening of the colon has been described in cats, but its imaging and clinicopathological features remain poorly understood.

OBJECTIVES

Description of the signalment, clinical presentation, imaging, endoscopic and histological features of short colon syndrome in cats.

ANIMALS

Ninety-three cats diagnosed with short colon.

METHODS

Multi-institutional, descriptive, retrospective case series study. Medical records were searched for a diagnosis of short colon on abdominal ultrasonography, computed tomography, endoscopy, autopsy, or a combination of these modalities.

RESULTS

The median age of included cats was 12 years at the time of diagnosis. Diarrhea was the most common clinical sign (60/92; 65%), followed by vomiting (36/92; 39%), weight loss (36/92; 39%), and inappetence (24/92; 26%). Thirteen percent of cats (12/92) had no signs of gastrointestinal disease at the time of diagnosis. In addition to a shortened colonic length, 79% (66/84) of cats had concomitant colonic thickening on ultrasonographic examination. On colonoscopy, mucosal ulcerations of the colonic wall were seen in 39% (9/23) of cats. Histopathologically, all cats but 1 (diagnosed simultaneously with colonic small cell lymphoma) had lymphoplasmacytic colitis, and when small intestinal biopsies were performed, concurrent lymphoplasmacytic enteritis or small cell lymphoma of the small intestine.

CONCLUSIONS AND CLINICAL IMPORTANCE

Lymphoplasmacytic colitis is seen commonly in cats with short colon, suggesting a potential link between these entities.

Histologic characterization of the major duodenal papilla and association with concurrent biliary, pancreatic, and intestinal pathology in cats

Conjoining of the major pancreatic duct and common bile duct at the major duodenal papilla (MDP) is suspected to predispose cats to the clinical syndrome of "triaditis." However, microanatomy of the MDP or presence of lesions at the MDP has not been assessed in cats with or without triaditis. The aims of this study were to characterize feline MDP histomorphology and to identify associations between MDP anatomy/disease and the presence of biliary, pancreatic, or intestinal inflammation or neoplasia. Histologic assessment was prospectively performed on the MDP, duodenum, jejunum, ileum, liver, and pancreas from 124 client-owned cats undergoing postmortem examination. The majority of cats (104/124, 84%) had a complex ductular network at the MDP, with no distinction between pancreatic and common bile ducts. Lymphoid aggregates at the MDP were common (63/124, 51%). Inflammation of the MDP (MDPitis) was present in 35 of 124 cats (28%) and was often concurrent with cholangitis, pancreatitis, or enteritis (32/35, 91%), but was only associated with enteritis (19/35, 54%, P < .05). Triaditis was less common (19/124, 15%), but was associated with both conjoined MDP anatomy (19/19, 100%, P < .05) and MDPitis (12/19, 63%, P < .05). Neoplasia was present in 37 of 124 cats (29%), with lymphoma (28/37, 78%) predominating. Enteropathy-associated T-cell lymphoma type 2 (EATL2) was most common (n = 16/37, 43%) and was associated with triaditis and MDPitis (P < .05). These findings suggest that anatomy, immune activation, and/or inflammation of the MDP may play a role in the pathogenesis of triaditis. Further studies are needed to elucidate the relationships between triaditis, MDPitis, and EATL2.

Gallbladder atrophy associated with pancreatitis: Clinical and advanced imaging diagnosis in a dog

Gallbladder atrophy (GBA) is characterised by a reduction in the size and volume of the gallbladder. In human medicine, it is well-established that GBA frequently occurs together with pathologies affecting the gallbladder and pancreas. However, to the best of our knowledge, there is currently a dearth of reported cases of GBA in dogs within the veterinary field. In this study, we present a case report of GBA in a 7-year-old Yorkshire Terrier. The diagnosis of GBA was confirmed using abdominal ultrasonography and advanced imaging techniques, including computed tomography, which were performed over a 4-year period. The patient initially presented with predominantly gastrointestinal symptoms, which were subsequently diagnosed and treated as pancreatitis. Concurrently, a gallbladder nodule and an anomalous structure suspected to be cholelithiasis were identified. However, during the 4-year follow-up, the gallbladder structure regressed, leaving only the presence of the gallbladder nodule. Notably, cholecystectomy was not performed, and apart from pancreatitis-related symptoms, the patient did not show any gallbladder-related problems throughout the spontaneous atrophic process. Based on these findings, we propose that the observed GBA was likely induced by cholecystitis associated with pancreatitis. This case underscores the significance of considering GBA as a potential diagnosis in canine patients presenting with pancreatitis and gastrointestinal symptoms. Furthermore, it highlights the value of comprehensive diagnostic imaging in accurately determining the underlying cause of these symptoms.

Fatty infiltration of the pancreas: a systematic concept analysis

Fatty infiltration of the pancreas (FIP) has been recognized for nearly a century, yet many aspects of this condition remain unclear. Regular literature reviews on the diagnosis, consequences, and management of FIP are crucial. This review article highlights the various disorders for which FIP has been established as a risk factor, including type 2 diabetes mellitus (T2DM), pancreatitis, pancreatic fistula (PF), metabolic syndrome (MS), polycystic ovary syndrome (PCOS), and pancreatic duct adenocarcinoma (PDAC), as well as the new investigation tools. Given the interdisciplinary nature of FIP research, a broad range of healthcare specialists are involved. This review article covers key aspects of FIP, including nomenclature and definition of pancreatic fat infiltration, history and epidemiology, etiology and pathophysiology, clinical presentation and diagnosis, clinical consequences, and treatment. This review is presented in a detailed narrative format for accessibility to clinicians and medical students.

ACVIM consensus statement guidelines on diagnosing and distinguishing low-grade neoplastic from inflammatory lymphocytic chronic enteropathies in cats

BACKGROUND

Lymphoplasmacytic enteritis (LPE) and low-grade intestinal T cell lymphoma (LGITL) are common diseases in older cats, but their diagnosis and differentiation remain challenging.

OBJECTIVES

To summarize the current literature on etiopathogenesis and diagnosis of LPE and LGITL in cats and provide guidance on the differentiation between LPE and LGITL in cats. To provide statements established using evidence-based approaches or where such evidence is lacking, statements based on consensus of experts in the field.

ANIMALS

None.

METHODS

A panel of 6 experts in the field (2 internists, 1 radiologist, 1 anatomic pathologist, 1 clonality expert, 1 oncologist) with the support of a human medical immunologist, was formed to assess and summarize evidence in the peer-reviewed literature and complement it with consensus recommendations.

RESULTS

Despite increasing interest on the topic for clinicians and pathologists, few prospective studies were available, and interpretation of the pertinent literature often was challenging because of the heterogeneity of the cases. Most recommendations by the panel were supported by a moderate or low level of evidence. Several understudied areas were identified, including cellular markers using immunohistochemistry, genomics, and transcriptomic studies.

CONCLUSIONS AND CLINICAL IMPORTANCE

To date, no single diagnostic criterion or known biomarker reliably differentiates inflammatory lesions from neoplastic lymphoproliferations in the intestinal tract of cats and a diagnosis currently is established by integrating all available clinical and diagnostic data. Histopathology remains the mainstay to better differentiate LPE from LGITL in cats with chronic enteropathy.

Vitamin B12 in Cats: Nutrition, Metabolism, and Disease

Cobalamin is a water-soluble molecule that has an important role in cellular metabolism, especially in DNA synthesis, methylation, and mitochondrial metabolism. Cobalamin is bound by intrinsic factor (IF) and absorbed in the ileal tract. The IF in cats is synthesized exclusively by pancreatic tissue. About 75% of the total plasma cobalamin in cats is associated with transcobalamin II, while in this species, transcobalamin I is not present. In cats, the half-life of cobalamin is 11-14 days. Diagnostic biomarkers for B12 status in cats include decreased levels of circulating total cobalamin and increased levels of methylmalonic acid. The reference interval for serum cobalamin concentrations in cats is 290-1500 ng/L, and for the serum methylmalonic acid concentration, it is 139-897 nmol/L. Therapy for hypocobalaminemia mainly depends on the underlying disease. In some cases, subcutaneous or intramuscular injection of 250 μg/cat is empirically administered. In recent years, it has been demonstrated that oral cobalamin supplementation can also be used successfully in dogs and cats as a less invasive alternative to parental administration. This review describes the current knowledge regarding B12 requirements and highlights improvements in diagnostic methods as well as the role of hypocobalaminemia in its associated diseases.

Relationship between Serum Protein Electrophoresis, Endoscopic and Histopathological Scores in 99 Cats with Chronic Enteropathy

Simple Summary

Serum protein electrophoresis (SPE) is a laboratory test used to separate different protein fractions. It is used to investigate animals with hyperglobulinemia and to distinguish between monoclonal and polyclonal gammopathies. SPE can also highlight acute or chronic inflammation patterns which are useful in disease monitoring. SPE is effective in humans with intestinal bowel disease (IBD) and chronic liver diseases. In addition, hypergammaglobulinemia is a marker of extraintestinal manifestations in human IBD patients, which often includes hepatic and pancreatic disease. Concurrent pancreatic and/or hepatic diseases in cats with chronic enteropathy (CE) have often been found, which may contribute to SPE alterations. The present study investigated the relationship between SPE and endoscopy, histopathology, and hepatic and pancreatic ultrasonographic findings in ninety-nine cats diagnosed with CE. No significant differences were observed between SPE and endoscopic and histopathological severity scores. Cats with concurrent pancreatic and/or hepatic ultrasonographic alterations showed lower albumin, lower α-globulin, and higher γ-globulin levels than cats diagnosed with enteropathy alone. This study suggests that hepatic and/or pancreatic alterations may influence SPE fractions in cats with CE, and should form the basis for further prospective studies on cats with diaditis and triaditis.

Abstract

Few studies have investigated total protein (TP) and serum protein electrophoresis (SPE) in cats with chronic enteropathy (CE). Cats diagnosed with CE were evaluated to investigate the relationships between TP, SPE and endoscopy, histopathology, and extraintestinal involvement. Medical records were searched for cats with a history of chronic gastrointestinal signs and a final diagnosis of CE. Information on signalment, TP, SPE, endoscopic score, histopathological diagnosis and score, and concurrent hepatic or pancreatic ultrasonographic alterations was collected. Relationships between protein profiles and other variables were investigated. Ninety-nine cats were included in the study, 63 diagnosed with various degrees of bowel inflammation and 36 with small-cell alimentary lymphoma. The most common TP alteration was hypoproteinemia (24%). No significant differences were observed between protein profiles and endoscopic and histopathological severity scores. Forty-five cats showing concurrent pancreatic and/or hepatic ultrasonographic alterations, had significantly lower albumin, lower α-globulin, and higher γ-globulin levels than cats not showing concurrent alterations. Disease severity scores did not seem to influence the protein profile in cats with CE. Extraintestinal involvement may be suspected in cats with lower albumin and α-globulins and higher γ-globulins.

Correlation between metabolomic profile constituents and feline pancreatic lipase immunoreactivity

Background

Feline pancreatic lipase immunoreactivity (fPLI) is commonly used to diagnose pancreatitis in cats (FP). Untargeted metabolomics has been extensively applied in human and veterinary medicine, but no metabolomic studies regarding FP have been conducted.

Objectives

To identify metabolites significantly associated with increased fPLI.

Animals

Forty‐nine client‐owned cats: 11 clinically healthy and 38 with various clinical conditions.

Methods

Analytical cross‐sectional study with convenience sampling. A panel of 630 metabolites belonging to 26 biochemical classes was quantified in plasma using a commercial metabolomic assay. The correlation between plasma metabolite concentrations and serum fPLI was evaluated using Spearman's rank correlation coefficient (R_s) with Bonferroni correction. Multivariable analysis then was performed to control for glomerular filtration rate, liver damage, and blood glucose concentration. The accuracy of selected metabolites in discriminating between cats with normal (≤3.5 μg/L) and increased (>5.3 μg/L) fPLI was estimated using the area under the receiver operating characteristic curve (AUROC).

Results

Four hundred and seven of 630 metabolites (64.6%) were quantified in all cats. When controlled for potential confounders only 3 sphingolipids were significantly positively correlated with fPLI: 2 cerebrosides: HexCer(d18:1/24:0); (R_s = .56), and HexCer(d18:1/24:1); (R_s = .58) and 1 sphingomyelin: SM C18:0 (R_s = .55). Their AUROCs in identifying cats with increased fPLI were 82% (95% confidence interval [CI 95%], 70%‐94%), 84% (CI 95%, 72%‐96%), and 78% (CI 95%, 65%‐92%), respectively.

Conclusions and Clinical Importance

Selected sphingolipids are moderately positively correlated with fPLI and appear to have fair to moderate diagnostic accuracy in discriminating between cats with normal and increased fPLI.

Pancreatic candidiasis in a cat

Case summary

An 11-year-old female spayed Maine Coon cat was referred for assessment of hyporexia, weight loss, vomiting and diarrhoea. An abdominal ultrasound revealed an enlarged and hypoechoic pancreas containing two large fluid-filled structures. Fine-needle aspiration of the cyst-like structures was performed, and cytology revealed moderate-to-marked predominantly suppurative inflammation with yeast cells. Candida glabrata was cultured from the fluid. The patient was treated with oral itraconazole and the clinical signs resolved, although repeat abdominal ultrasound and cytology revealed persistence of the infected cyst-like structures. The patient remained asymptomatic for 8 months after the discontinuation of antifungal medications, despite the persistence of the pancreatic infection with C glabrata.

Relevance and novel information

To our knowledge, this is the first report of pancreatic infection with Candida species in a cat, followed by a chronic subclinical infection persisting for at least 8 months after treatment discontinuation.

Cyclosporine Treatment in Cats with Presumed Chronic Pancreatitis-A Retrospective Study

Simple Summary

Chronic pancreatitis (CP) is a common disease in middle-aged to older cats. Cyclosporine, an immunosuppressive drug, has been suggested as an alternative treatment when other drugs that suppress inflammation are ineffective or unsuitable. However, no published studies have investigated its efficacy in cats with CP. The aim of this retrospective study was to evaluate the efficacy of cyclosporine as a treatment for pancreatitis in cats with presumed CP. All cats had a history and clinical signs suggestive of CP and blood samples showed abnormally high concentrations of feline pancreas-specific lipase (Spec fPL) on at least two occasions. This is common in CP. All cats were treated with cyclosporine for at least three weeks. Nineteen cats, aged 6.9–17.5 years, were included. Daily treatment with cyclosporine resulted in an improvement of serum Spec fPL concentrations which indicates that the pancreatic inflammation likely had improved. The study has several limitations, including different treatment durations and doses, lack of biopsies to confirm CP and the treatment effect was not compared with an untreated control group. Despite the limitations, our results suggest that cyclosporine treatment decreases serum Spec fPL concentrations and may be effective in the management of feline chronic pancreatitis.

Abstract

Chronic pancreatitis (CP) is a common disease in middle-aged to older cats. Cyclosporine has been suggested as an alternative treatment when other immunosuppressive treatments are insufficient or contraindicated. However, no published studies have investigated its efficacy on feline CP. The aim of this retrospective study was to evaluate the efficacy of cyclosporine on supranormal serum feline pancreas-specific lipase (Spec fPL) concentrations in cats with presumed CP. Inclusion criteria were history and clinical signs suggestive of CP, serum Spec fPL concentrations above 5.3 μg/L (reference range 0–3.5 μg/L, equivocal range 3.6–5.3 μg/L) on at least two occasions and treatment with cyclosporine for at least three weeks. Serum Spec fPL was analyzed at Idexx Laboratories, Kornwestheim, Germany. Nineteen cats, aged 6.9–17.5 years (median 11.6), were included. No pancreatic biopsies were available. Median (range) serum Spec fPL concentration was 14.2 μg/L (6.1–43.3) at baseline and 6.7 μg/L (0.9–23.6) at follow-up. Cyclosporine treatment (5.0–7.9 mg/kg orally SID) was associated with a significant reduction in serum Spec fPL concentrations (p < 0.001) at follow-up after 23–206 days (median 35). Body weight decreased significantly between inclusion and follow-up (p = 0.013). Significant improvement of clinical signs could not be measured (p = 0.781). This study has several limitations, including unstandardized treatment length and dose, no control group and lack of pancreatic biopsies. Despite the limitations, our results suggest that cyclosporine treatment reduces supranormal serum Spec fPL concentrations in cats with presumed CP.

Abdominal ultrasound and clinicopathologic findings in 22 cats with exocrine pancreatic insufficiency

BACKGROUND

Awareness of exocrine pancreatic insufficiency (EPI) in cats has increased since the development of an assay for feline trypsin-like immunoreactivity (fTLI). Ultrasound findings in cats with EPI have only been reported rarely and described as nonspecific.

HYPOTHESIS/OBJECTIVES

To describe the ultrasonographic findings, clinical signs, and concurrent diseases in cats with EPI.

ANIMALS

Twenty-two client-owned cats with EPI.

METHODS

Multicenter retrospective descriptive study including cats with serum fTLI concentration ≤8 μg/L and an abdominal ultrasound examination performed within 6 weeks of fTLI measurement. Sonographic measurements of maximal pancreatic thickness and maximal pancreatic duct diameter as well as ratios of pancreatic duct diameter to pancreatic thickness were obtained. Additional sonographic findings, concurrent conditions, and clinical signs were recorded.

RESULTS

The most common clinical sign was weight loss (15/22 cats). Chronic enteropathy was the most common concurrent disease (13/22 cats). In 39% of cats, the pancreas had minimal or no sonographic alterations. Pancreatic duct dilatation (>2.5 mm), pancreatic duct tortuosity with variable diameter, or both were seen in 6/13 cats. The pancreatic parenchyma was subjectively thin in 6 cats. A significant relationship was found between subjectively thin pancreatic parenchyma and increased pancreatic duct size : pancreatic thickness ratio (P = .004). Diffuse gastrointestinal dilatation with echogenic content was observed in 8/22 cats.

CONCLUSION

Exocrine pancreatic insufficiency often causes minimal to no sonographic pancreatic changes. Nonetheless, the findings of thin pancreatic parenchyma, pancreatic duct dilatation, or diffuse small intestinal dilatation with echogenic contents in cats with unexplained weight loss or unformed feces should raise clinical suspicion for EPI.

2021 AAFP Feline Senior Care Guidelines

The '2021 AAFP Feline Senior Care Guidelines' are authored by a Task Force of experts in feline clinical medicine and serve as an update and extension of those published in 2009. They emphasize the individual patient evaluation and the process of aging, with references to other feline practice guidelines for a more complete discussion of specific diseases. Focusing on each cat encourages and empowers the owner to become a part of the cat's care every step of the way. A comprehensive discussion during the physical examination and history taking allows for tailoring the approach to both the cat and the family involved in the care. Videos and analysis of serial historical measurements are brought into the assessment of each patient. These Guidelines introduce the emerging concept of frailty, with a description and methods of its incorporation into the senior cat assessment. Minimum database diagnostics are discussed, along with recommendations for additional investigative considerations. For example, blood pressure assessment is included as a minimum diagnostic procedure in both apparently healthy and ill cats. Cats age at a much faster rate than humans, so practical timelines for testing frequency are included and suggest an increased frequency of diagnostics with advancing age. The importance of nutrition, as well as senior cat nutritional needs and deficiencies, is considered. Pain is highlighted as its own syndrome, with an emphasis on consideration in every senior cat. The Task Force discusses anesthesia, along with strategies to allow aging cats to be safely anesthetized well into their senior years. The medical concept of quality of life is addressed with the latest information available in veterinary medicine. This includes end of life considerations like palliative and hospice care, as well as recommendations on the establishment of 'budgets of care', which greatly influence what can be done for the individual cat. Acknowledgement is given that each cat owner will be different in this regard; and establishing what is reasonable and practical for the individual owner is important. A discussion on euthanasia offers some recommendations to help the owner make a decision that reflects the best interests of the individual cat.

Feline chronic enteropathy

Feline chronic enteropathy is a common disorder, especially in the senior cat population, with rising incidence over the past decade. Feline chronic enteropathy is considered an umbrella term comprising different diseases including food-responsive enteropathy, idiopathic inflammatory bowel disease and alimentary small cell lymphoma. However, differentiation between those diseases is often difficult in practice. This review will discuss the clinical approach to cats with chronic enteropathy, state-of-the-art diagnostic tests and pitfalls thereof as well as current therapeutic approaches. Although, much of the etiopathogenesis is still unknown, increased research efforts in this field have brought new insights into diagnostic and therapeutic options for these cats.

ACVIM consensus statement on pancreatitis in cats

Background

Pancreatitis in cats, although commonly diagnosed, still presents many diagnostic and management challenges.

Objective

To summarize the current literature as it relates to etiology, pathogenesis, diagnosis, and management of pancreatitis in cats and to arrive at clinically relevant suggestions for veterinary clinicians that are based on evidence, and where such evidence is lacking, based on consensus of experts in the field.

Animals

None.

Methods

A panel of 8 experts in the field (5 internists, 1 radiologist, 1 clinical pathologist, and 1 anatomic pathologist), with support from a librarian, was formed to assess and summarize evidence in the peer reviewed literature and complement it with consensus clinical recommendations.

Results

There was little literature on the etiology and pathogenesis of spontaneous pancreatitis in cats, but there was much in the literature about the disease in humans, along with some experimental evidence in cats and nonfeline species. Most evidence was in the area of diagnosis of pancreatitis in cats, which was summarized carefully. In contrast, there was little evidence on the management of pancreatitis in cats.

Conclusions and Clinical Importance

Pancreatitis is amenable to antemortem diagnosis by integrating all clinical and diagnostic information available, and recognizing that acute pancreatitis is far easier to diagnose than chronic pancreatitis. Although both forms of pancreatitis can be managed successfully in many cats, management measures are far less clearly defined for chronic pancreatitis.

Obstructive pancreatolithiasis in a cat with triaditis and concurrent hypercalcaemia

Case summary

A 7-year-old neutered female domestic longhair cat was presented for further investigation of suspected hepatobiliary disease. Increases in serum 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester lipase and hepatobiliary enzymes, with concurrent hypoalbuminaemia, were documented on blood biochemistry. Abdominal ultrasonography findings were consistent with acute pancreatitis with multiple pancreatoliths visualised within the pancreatic duct. Treatment for suspected triaditis was initiated with a hydrolysed protein diet, amoxicillin-clavulanate, hepatoprotectants and buprenorphine. Fifty-three days later, the patient presented with hypercalcaemia and obstructive pancreatolithiasis, and was euthanased. Post-mortem examination revealed severe chronic active pancreatitis with moderate chronic lymphocytic, plasmacytic cholangiohepatitis and mild chronic lymphocytic-plasmacytic duodenal enteritis (triaditis). Multiple calcium carbonate pancreatoliths present within the pancreatic ducts had resulted in pancreatic duct obstruction.

Relevance and novel information

Pancreatolithiasis is a very rare condition in cats, with only five reports to date. In human medicine, pancreatolithiasis is often a sequala to chronic pancreatitis, seen in up to 50-90% of patients. However, in cats the aetiology of pancreatolithiasis, and indeed chronic pancreatitis, is poorly understood. This report describes a case of obstructive pancreatolithiasis in a cat with histopathological confirmation of triaditis and is the first report of hypercalcaemia in a cat with obstructive pancreatolithiasis. This further adds to the evidence base that pancreatolithiasis may have a similar pathogenesis to humans and can develop secondarily to chronic pancreatitis in cats.

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.

Retrospective study of the relative frequency of feline hepatobiliary disease in New Zealand based on 10 years of hepatic biopsy samples

Aims

To retrospectively determine the relative frequency of feline hepatobiliary diseases from biopsy specimens submitted to a single laboratory across a 10-year period and to establish whether age, sex or breed associations exist.

Methods

Histopathological data from 154 liver biopsies of New Zealand cats sampled between 2008 and 2018 were analysed. The samples were allocated to primary, secondary and tertiary disease categories using criteria established by the World Small Animal Veterinary Association. Breed associations were derived using ORs and 95% CIs. Gender and age associations were also evaluated.

Results

The most frequently diagnosed hepatobiliary diseases were lymphocytic cholangitis (20 per cent), hepatitis (16.9 per cent), reversible hepatocellular injury (16.4 per cent), neutrophilic cholangitis (9.7 per cent), haematopoietic neoplasia (9.7 per cent), hepatocellular neoplasia (5.6 per cent) and cholangiocellular neoplasia (4.1 per cent). Burmese cats were found to be at significantly increased risk of both biliary and parenchymal diseases and Birman cats to be at significantly increased risk of parenchymal disease. Domestic longhair cats were at significantly increased risk of hepatobiliary neoplasia. Birman cats were at significantly increased risk of hepatitis while domestic shorthair cats were at significantly decreased risk of neutrophilic cholangitis, reversible hepatocellular injury and hepatitis.

Conclusions

This study is the first retrospective examination of the relative frequency of hepatobiliary disease in biopsy specimens from New Zealand cats. Some breeds were associated with specific histopathology.

Candida albicans cholecystitis with associated hepatitis in a cat

Case summary

A 3-year-old male neutered domestic shorthair cat was presented for vomiting, inappetence and icterus. Biochemical results and ultrasonographic findings were consistent with cholestasis and possible biliary obstruction. A diagnosis of Candida albicans cholecystitis with associated hepatitis was made following cytologic examination and fungal culture. Progressive hyperbilirubinemia and hepatic encephalopathy were ultimately fatal.

Relevance and novel information

To our knowledge, this is the first report of biliary candidiasis diagnosed by cytologic examination of a cholecystocentesis sample in a domestic animal with no evidence of immunodeficiency. Additionally, this is the first reported case of fungal cholecystitis with associated white bile syndrome due to obstructive cholestasis, without an overt gall bladder mucocele.

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.

A retrospective study of 157 hospitalized cats with pancreatitis in a tertiary care center: Clinical, imaging and laboratory findings, potential prognostic markers and outcome

BACKGROUND

Pancreatitis in cats (FP) has been increasingly diagnosed in recent years, but clinical studies of large numbers of affected cats are scarce.

OBJECTIVES

To describe a large cohort of cats with FP requiring hospitalization.

ANIMALS

One hundred and fifty-seven client-owned cats.

METHODS

Retrospective study, including cats diagnosed with pancreatitis based on sonographic evidence, positive SNAP feline pancreatic lipase immunoreactivity test results, increased 1,2-o-dilauryl-rac-glycerol-glutaric Acid-(6'-methylresorufin ester)-lipase activity, histopathology, or some combination of these.

RESULTS

One-hundred and twenty-two cats (77.7%) survived to discharge. Median time from onset of clinical signs to presentation was longer (P = .003) in nonsurvivors. Causes of FP included recent general anesthesia, trauma, hemodynamic compromise, and organophosphate intoxication, but most cases (86.6%) were idiopathic. Ultrasonographic findings consistent with pancreatitis were documented in 134 cats, including pancreatomegaly (81.3%), decreased (31.3%), or increased (14.9%) pancreatic echogenicity, extra-hepatic biliary tract dilatation (24%), and increased peri-pancreatic echogenicity (13%). Lethargy (P = .003), pleural effusion (P = .003), hypoglycemia (P = .007), ionized hypocalcemia (P = .016), azotemia (P = .014), parenteral nutrition administration (P = .013), and persistent anorexia during hospitalization (P = .001) were more frequent in nonsurvivors, whereas antibiotics were more frequently administered to survivors (P = .023). Nevertheless, when Bonferroni's correction for multiple comparisons was applied, none of the variables was statistically significant.

CONCLUSIONS AND CLINICAL IMPORTANCE

Previously unreported, clinically relevant, potential prognostic factors, including hypoglycemia, azotemia, parenteral nutrition, and withholding antibacterial treatment were identified in this exploratory study. These preliminary results should be examined further in confirmatory studies.

Diagnosis of pancreatic disease in feline platynosomosis

Objectives Platynosomum species are cat-specific parasitic trematodes that parasitize the biliary ducts and gall bladder. Due to the common connection to the major duodenal papilla of the pancreas and common bile ducts in addition to the periductal proximity of the pancreas, it is possible that platynosomosis could cause pancreatitis. The objective of this study was to determine whether platynosomosis, a commonly diagnosed parasitic disease in cats on St Kitts, has any association with pancreatic disease. Methods To investigate this possibility, the pancreas of free-roaming cats with naturally acquired platynosomosis were evaluated via ultrasound, serum concentrations of feline pancreatic lipase (fPL), cobalamin, folate and feline trypsin-like immunoreactivity (fTLI) and histopathology. Twenty free-roaming, young adult, feral cats, positive for feline immunodeficiency virus, and diagnosed with Platynosomum species infection via fecal analysis were recruited. The liver, biliary system and pancreas were evaluated via ultrasonography during a short duration anesthesia. Serum concentrations of fPL, fTLI, folate and cobalamin were measured. Sections of the right limb, left limb and body of the pancreas were evaluated histopathologically using hematoxylin and eosin (H&E) stain. Results None of the cats had sufficient criteria to fulfill the ultrasonographic diagnosis of pancreatitis. One cat had an elevated fPL concentration in the range consistent with pancreatitis. Four cats had cobalamin deficiencies and 11 had abnormal folate concentration. The fTLI concentration was equivocal for the diagnosis of exocrine pancreatic insufficiency in one cat. With a single exception, histopathology changes, when present (n = 12), were mild, non-specific and predominantly characterized by lymphocytic infiltrates and fibrosis. The exception was a cat that presented a chronic interstitial and eosinophilic pancreatitis of slightly increased severity, likely the result of platynosomosis. Conclusions and relevance The results of this study suggest that platynosomosis rarely induces pancreatic damage in cats. With only one exception, chronic pancreatitis diagnosed in cats with fluke-induced cholangitis and cholangiohepatitis was subtle and interpreted as an incidental background lesion unrelated to platynosomosis.

A real-time reporting system of causes of death or reasons for euthanasia: A model for monitoring mortality in domesticated cats in Taiwan

A novel, real-time mortality recording system was designed to collect mortality data in companion animals from veterinary hospitals in Taiwan. This retrospective study aims to introduce the system, and to utilize the data collected for further investigation of the lifespan and mortality of the domesticated cat population stratified by demographic variables. Our data revealed that 1325 domesticated cats were acquired between 2012 and 2014. The median age of the study population was 8.0 years (IQR 3.0–13.0; range 0.0–22.7). Neutered and purebred cats lived longer. The most common causes of death were renal and urologic disorders, followed by neoplasia, infection, cardiovascular disorders, and trauma. Independent factors for common causes were surveyed. Advanced age and neutering was found to be associated with death due to renal and urologic disorders as well as with neoplasia. In contrast, younger age was found to be associated with death due to trauma and infection; being unneutered and living in the capital city were found to be associated with death due to trauma. Being male or purebred was found to be associated with death due to cardiovascular disorders.

Feline Exocrine Pancreatic Insufficiency: A Retrospective Study of 150 Cases

Background

Little information is available about the clinical presentation and response to treatment of cats with exocrine pancreatic insufficiency (EPI).

Objectives

To describe the signalment, clinical signs, concurrent diseases, and response to treatment of cats with EPI.

Animals

One hundred and fifty cats with EPI.

Methods

Retrospective case series.

Results

Questionnaires were sent to 261 veterinarians, and 150 (57%) were returned with data suitable for statistical analysis. The median age of the cats with EPI was 7.7 years. The median body condition score was 3 of 9. Ninety‐two of 119 cats (77%) had hypocobalaminemia, and 56 of 119 cats (47%) had increased and 6 of 119 cats (5%) had decreased serum folate concentrations. Clinical signs included weight loss (91%), unformed feces (62%), poor hair coat (50%), anorexia (45%), increased appetite (42%), lethargy (40%), watery diarrhea (28%), and vomiting (19%). Eighty‐seven cats (58%) had concurrent diseases. Treatment response was reported to be good in 60%, partial in 27%, and poor in 13% of 121 cats. Trypsin‐like immunoreactivity <4 μg/L was associated with a positive response to treatment (OR, 3.2; 95% CI, 1.5–7.0; P = .004). Also, cobalamin supplementation improved the response to treatment (OR, 3.0; 95% CI, 1.4–6.6; P = .006).

Conclusions and Clinical Importance

Exocrine pancreatic insufficiency in cats often has a different clinical presentation than in dogs. The age range for EPI in cats is wide, and many cats can be ≤5 years of age. Most cats respond well to appropriate treatment for EPI, and cobalamin supplementation appears to be necessary for a good response.

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.

Comparison of Serum Spec fPL(™) and 1,2-o-Dilauryl-Rac-Glycero-3-Glutaric Acid-(6'-Methylresorufin) Ester Assay in 60 Cats Using Standardized Assessment of Pancreatic Histology

BACKGROUND

Feline pancreas-specific lipase (Spec fPL) is considered a useful test for the antemortem diagnosis of pancreatitis in cats. A recent study found good agreement between the results of the Spec fPL and catalytic 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester (DGGR) lipase assay. Prospective studies evaluating their sensitivity and specificity are lacking.

OBJECTIVES

To compare the results of the Spec fPL and the DGGR assays with a standardized histologic assessment of the pancreas.

ANIMALS

Sixty client-owned cats presented for necropsy.

METHODS

PROSPECTIVE STUDY

Spec fPL concentrations and serum DGGR lipase activity were measured from the same blood sample. The pancreas was removed within 3 hours after euthanasia; serial transverse sections were made every 0.5 cm throughout the entire pancreas and reviewed using a histologic grading scheme. Sensitivity and specificity for the Spec fPL and DGGR assay results were determined.

RESULTS

The sensitivity and specificity for the Spec fPL assay (cutoff value ≥5.4 μg/L) was 42.1 [95% confidence interval (95% CI), 29.4-55.9%] and 100% (95% CI, 31.0-100.0%). The sensitivity and specificity for the DGGR assay (cutoff value >26 U/L) was 36.8 (95% CI, 24.7-50.7%) and 100% (95% CI, 31.0-100.0%). When lymphocytic inflammation up to 10% of a section was considered normal, the sensitivity and specificity for Spec fPL assay (cutoff value ≥5.4 μg/L) was 61.1 (95% CI, 36.1-81.7%) and 69.0% (95% CI, 52.8-81.9%) and the sensitivity and specificity for the DGGR assay (cutoff value >26 U/L) was 66.7 (95% CI, 41.2-85.6%) and 78.6% (95% CI, 62.8-89.2%).

CONCLUSIONS AND CLINICAL IMPORTANCE

Both lipase assays performed similarly well, but their agreement with histologic pancreatic inflammation was limited.