Sonopath Forum

To Mucocele or Not to Mucocele

13 year old Fox terrier presented most recently for anorexia and weight loss
Had IMHA some years back that resolved on prednisone therapy which was eventually discontinued
Presented some months back for pemphigus foliaceus around the lips which resolved on Doxycycline and Niacinamide therapy.
All meds were discontinued but anorexia persists
Chemistry profile shows new elevation in liver enzymes: ALP=432 mcl/L, ALT=777mcl/L
Serum bile acids are elevated (post was 75).

13 year old Fox terrier presented most recently for anorexia and weight loss
Had IMHA some years back that resolved on prednisone therapy which was eventually discontinued
Presented some months back for pemphigus foliaceus around the lips which resolved on Doxycycline and Niacinamide therapy.
All meds were discontinued but anorexia persists
Chemistry profile shows new elevation in liver enzymes: ALP=432 mcl/L, ALT=777mcl/L
Serum bile acids are elevated (post was 75).
ACTH stim shows elevated pre cortisol level of 6.4mcg/dL but normal 1 hour post of 14.3mcg/dL.
Abdominal US shows left renal pyelectasia with no obvious obstructions and moderate to markedly enlarged gallbladder full of clumping sludge. The liver parenchyma appeared normal. The gallbladder wall is not thickened and there is no Murphy’s sign. The intraluminal debris does appear to be at least partially gravity dependent. The patient was fasted for this study.
US guided fna’s were done on the liver as well as cystocentesis for urinalysis and culture.
Differential diagnoses for the elevated liver enzymes, elevated bile acids, and anorexia include cholangiohepatitis, chronic hepatitis, infectious disease (Lepto), and neoplasia.
I am hesitant to call this a mucocele due to the above info (gravity dependent, no wall thickening, no inflammation) yet I am not fully comfortable with the appearance of the intraluminal debris. Any other thoughts?
Would it be ok to include ursodiol as part of medical management or not due to possibility of mucocele formation? Could the gallbladder be the cause of the anorexia and elevated liver enzymes?

Comments

June 26, 2016 at 2:01 pm -

There is still some movement

There is still some movement of the bile but there is also striating bile and overdistention. I use the movement of bile as criteria for emerging GBM and try medical on these. Given the imha hx im guessing pred was involved and cortisone predisposes to mucocele formation whether coming from endogenous or exagenous sources..

I like actigal for 8 weeks and baytril metro for 3 weeks and watch the sap alt bili and GGT a few times along the way. Rapidly rising sap is a yellow flag on these and of course good note on negative murphy sign. No inflammatory pattern so can go conservative on this one for the moment.

GB motility study is another option to assess function. Check out the description of GBM study here in interventional procedures:

http://sonopath.com/resources/interventional-procedures