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Sudden Onset of Jaundice and Anorexia in an 8-year-old DSH Feline: Case Of the Month July 2017

Patient Information

Age
8 Years
Species
Feline

Keywords

Clinical Signs

Urinalysis

Blood Chemistry

Exam Findings

Images

Lateral radiograph showing cholelith.
VD radiograph of cholelith.
1st image showcasing color flow around the duodenal papilla. Also note in the 1st and 2nd image the hypoechoic pancreas, and surrounding hyperechoic, reactive fat and mesentery. Image 3 utilizes elastography, a technique that exploits the fact that a pathological process alters the elastic properties of involved tissue,i.e. "tissue stiffness".
1st image showing single shadowing cholelith in the duodenal papilla; 2nd image showing discreet mass originating from the duodenum
Showcasing the impeccably detailed duodenal papilla with cholelith, duodenum and duodenal mass all in one image
Aspirating fluid from the CBD and GB.
Intestinal mass outlined in surgery.
Removing the cholelith.
Cholelith.

This month SonoPath presents an artistic example of sonographic pathology from one of the original consummate GP sonographers & surgeons of our time, Dr. Robert Hylands of Westbridge Veterinary Hospital in Mississauga, Ontario, Canada.  Since the 1980s when clinical sonography entered the veterinary scene in serious fashion, Bob has been at the forefront as a luminary and influencer and has always been one of the top clinincal sonographers. Here is just one more rock star example case of bile duct obstruction in a cat with some hidden pathology to accompany it in true Hylands Picasso fashion. Take a look at this sonographic and surgical display and you will see what we mean. :)

History

An 8-year-old DSH feline was presented with an acute presentation of jaundice and decreased appetite. He was also pyrexic (40.6 celsius). Blood chemistry: ALT 669, AST 177, TBil 34, ALKP 48, PLI 50, SDMA 14, T4 22. CBC: normocytic normochromic anemia HCT 28% with reticulocyte 11 (<50) non-regenerative. Urinalysis by cysto; spec. gr 1.047, ph 6.5, Bil3+, prot 2+, RBC>50, WBC 3-5, sq ep 1-5, trans ep 1-5. FELV/FIV NEG. Abdominal radiographs clearly demonstrated the presence of a radiopaque density (3 mm) that appears to image in the vicinity of where the major duodenal papilla would be located. The cat has lost almost 0.9 KG (1.9 lbs) over the last year. An abdominal ultrasound was ordered to evaluate the cause of the elevated Tbil and jaundiced appearance of the individual.

Image Interpretation

The liver displayed signs of cholangitis. The gallbladder wall was thickened, double lined and the mucosal surface was irregular with a feathery appearance. The CBD was distended with anechoic fluid and had a thickened wall as well. The major duodenal papilla had a single cholelith wedged within it and was causing the obstruction. The pancreas was hypoechoic and mottled with hyperechoic poorly outlined densities. The surrounding fat and mesentery were both reactive and markedly hyperechoic. A few mm distal to the area of the papilla was a discreet mass that was originating from the opposite side of the duodenum.

DX

Cholangitis, obstructive cholelith in the papilla, regional peritonitis, pancreatitis, B cell intestinal lymphoma.

Outcome

The patient underwent abdominal surgery to remove the cholelith from the papilla. The mass was removed at the same time and a partial intestinal anastomosis performed. This was rather difficult as it was located only millimeters distal to the area of the papilla which needed to be preserved. Biopsies were taken of the kidneys, pancreas, liver and the intestinal mass. Over 15 mls of fluid was aspirated from the CBD to help relieve the intra hepatic accumulations of bile. The cat made a full recovery and was eating well within two days of his surgery. Final biopsy results were the following: neutrophilic cholangiohepatitis, interstitial nephritis, fibrosing pancreatitis, large b cell intestinal lymphoma. The owners opted for no further treatments for their cat as they were worried that the medications may affect their pregnancy. The cat succumbed 5 months later at an emergency clinic from unrelated respiratory issues.

Videos

Gallbladder wall thickened, double lined with irregular mucosal surface
Distended CBD with anechoic fluid and thickened wall. Note the shadowing single cholelith wedged in the duodenal papilla
Short axis view of the cholelith wedged in the duodenal papilla; also another view of the dilated, fluid filled CBD