A 10 year-old M/C Sheltie is presented for vague signs including ADR, vomiting and anorexia.
Physical Exam: On physical exam, the patient is quiet but alert and responsive. He is clearly icteric with some abdominal pain.
Preop blood work: Blood work was performed to investigate liver function. After the blood sample was drawn, the patient was placed on IV fluids, metoclopramide and buprenorphine.
A 10 year-old M/C Sheltie is presented for vague signs including ADR, vomiting and anorexia.
Physical Exam: On physical exam, the patient is quiet but alert and responsive. He is clearly icteric with some abdominal pain.
Preop blood work: Blood work was performed to investigate liver function. After the blood sample was drawn, the patient was placed on IV fluids, metoclopramide and buprenorphine.
Relevant blood chemistry abnormalities included:
* Total bilirubin of 14 (Referance Range: 0.1-0.6 mg/dl)
* ALT >2000 (RR 10-90 U/l)
* Alk. Phos. of 641 (RR 0-90 U/l)
* GGT of 17 (RR 0-7 U/l)
Imaging: Abdominal radiographs are fairly unremarkable besides poor detail in the cranial abdomen. Abdominal ultrasound was then recommended. It confirmed the suspicion of gallbladder disease, most likely a mucocele related to extra- hepatic biliary obstruction.
Two important precautions: Additional pre-operative testing included a clotting profile since coagulation may be compromised. Biliary obstruction affects fat and vitamin K absorption, and in turn, synthesis of coagulation factors 7, 9 and 10. Vitamin K1 was therefore started at 0.5 mg/kg BID. Ideally, it should be started 24 hrs preop and continued 2-4 days postop
Because up to 40% of mucoceles contain infected bile, Toby was started on IV antibiotics. Bacteria involved may include E. coli, Klebsiella, Enterobacter, Proteus or Pseudomonas. Good antibiotic options include cephalosporins, clindamycin, enrofloxacin, ticarcillin and clavulanic acid, amikacin or metronidazole. We opted for a combination of IV cefazolin and metronidazole.
Surgery: Once the patient was stable, an exploratory laparotomy was scheduled. Surgery revealed a grossly distended gallbladder compatible with a mucocele. The gallbladder was removed (cholecystectomy). After surgery, the bile was cultured (aerobic and anaerobic) and the gallbladder was biopsied. The next mandatory step is to check the patency of the common bile duct via a short incision in the duodenum (duodenotomy). The papilla was identified and the common bile duct was catheterized with a 3.5 red rubber catheter and flushed with sterile saline. This procedure yielded a large amount of thick, inspissated bile. All other abdominal organs appeared within normal limits. After a wedge liver biopsy was harvested, the abdomen was lavaged and closed in a standard fashion.
Postop results: Toby was kept on IV fluids, antibiotics and buprenorphine overnight. The next day, blood work was performed. The total bilirubin had decreased substantially: it dropped to 2.6 mg/dl, compared to the initial reading of 14 (RR 0.1-0.6). Toby looked bright, alert, responsive and comfortable. He ate spontaneously and was scheduled to go home.
Histopathology: Both cultures were negative. The liver biopsy revealed fibrosis and chronic cholangio-hepatitis. The gallbladder biopsy confirmed a mucocele with cholecystitis.
Outcome: Toby presented 6 weeks postop for an unrelated issue. Blood work was performed by the referring vet. Bilirubin and liver values were back to normal and Toby was feeling great.