Case Study

Inflamed gallbladder mucocele with mucoduct and micro hepatica in a 13 year old MN Bichon

Bichon, NM, 13 years. annual exam – doing well, PU/PD – but per owner has always been PU/PD, increased liver values, h/o surgically corrected Portosystemic shunt in 11 years ago. ALKP 439, ALT 862, AST 168, albumin 2.5, globulins 4.4, BUN subnormal at 5, white count 17.7, urine specific gravity 1.009.

DX

: Microhepatica. Mild to moderate remodeling. Inflamed gallbladder mucocele. Mucoduct. Concurrent hepatic parenchymal changes.

Image Interpretation

The liver in this patient was subnormal in size in short axis. The liver measured 1.36 cm in width with coarse architecture and heterogenous parenchymal changes were noted. The common bile duct was dilated at 0.57 cm with echogenic debris. This is likely mucoduct.

The pancreas was slightly hypoechoic and mildly swollen. If any pain upon imaging was noted then low grade inflammation is likely. The gallbladder in this patient presented suspended, immobile debris. An inflammatory pattern was noted around the neck of the gallbladder. This is consistent with inflamed gallbladder mucocele.

The right kidney measured 4.7 cm and was mildly swollen with moderate degenerative changes and interstitial nephrosis pattern. The left kidney measured 4.46 cm with thickened cortices and some loss of corticomedullary definition.

Outcome

Minor, concurrent pancreatitis and likely urinary tract infection.
Concernfor the subnormal albumin and BUN, which would suggest emerging hepatic failure. Given the patient’s history acute phase disease such as inflamed mucocele is a significant issue and more so than in a patient with normal hepatic capacity. Immediate cholecystectomy and common bile duct lavage is recommended. Renal biopsy could be considered especially on the right renal cortex given the chronic PU/PD in this patient. The right adrenal gland should be investigated given the right adrenal gland nodule. Right adrenalectomy could be considered even though the nodule is relatively small. I recommend the following support in the meantime until surgery can be performed. Guarded prognosis. Liver biopsy is essential to assess for parenchymal changes including that of concurrent portal vein hypoplasia as well as chronic inflammatory disease. Serial blood pressure measurements are recommended as well as eventual LDDST given the PU/PD and right adrenal nodule. However,it is not recommended this at the current time given the acute phase disease and the high risk of false positive.