Case Study

03_00172 Skittles B Biliary calculi

A 12-year-old FS Malti-poo with a history of seizures and unregulated diabetes, was presented for seizure activity. She was admitted immediately and given diazepam (Valium®) via I.V. catheter. The physical exam following the injection of diazepam found the patient to be quiet, and obtunded. She had tacky pale pink mucous membranes, bilateral cataracts, and mild hepatomegaly. She was also obese. In-house blood chemistry revealed hyperphosphatemia and hyperglycemia. CBC was within normal limits. The urine was slightly turbid in appearance.

A 12-year-old FS Malti-poo with a history of seizures and unregulated diabetes, was presented for seizure activity. She was admitted immediately and given diazepam (Valium®) via I.V. catheter. The physical exam following the injection of diazepam found the patient to be quiet, and obtunded. She had tacky pale pink mucous membranes, bilateral cataracts, and mild hepatomegaly. She was also obese. In-house blood chemistry revealed hyperphosphatemia and hyperglycemia. CBC was within normal limits. The urine was slightly turbid in appearance. The pH and specific gravity were within normal limits, but proteinuria (1+), glycosuria (3+), and hematuria (3+) were present. The patient had three more seizures throughout the day and diazepam was administered each time. She was started on phenobarbital while hospitalized and once stabilized, she was discharged with oral phenobarbital. The dog re-presented several days later for recurring seizures, in addition to weakness (‘her legs would give out’) and twitching. A grade II/VI left-sided systolic heart murmur was ausculted. In-house blood chemistry revealed improvement of the hyperphosphatemia and marked hypoglycemia. CBC was within normal limits. The PCV/TP were 44%/8 g/dL. Radiographs showed severe hepatomegaly. Corn syrup was administered orally.

DX

Common bile duct and lobar biliary calculi , renal mineralization, bladder calculus, UTI

Sonographic Differential Diagnosis

Common bile duct and lobar biliary calculi and visibly painful.

Image Interpretation

The liver presented swollen contour with relatively uniform parenchyma. The gallbladder presented a minor amount of debris and some echogenic suspended debris. Lobar calculi were noted as well as common bile duct calculi the largest of which was 0.8cm. The patient was visibly painful when imaging this structure. No evidence of perforation was noted, however this calculus was too large to pass in the common bile duct which was mildly dilated and distended. No pathology at the level of the duodenal papilla was noted.

Clinical Differential Diagnosis

Unregulated diabetes mellitus; the hypoglycemic episodes may be due to the Somogyi effect, however, neoplasms causing hypoglycemia must also be considered (for example, leiomyoma, leiomyosarcoma). Seizure activity may be due to granulomatous meningoencephalitis (and not related to hypoglycemia) or a brain tumor. Hepatomegaly likely due to the diabetes mellitus, however, further diagnostics to rule out hepatic disease should be considered based upon her breed and the predisposition to chronic active hepatitis.

Sampling

Patient was visibly painful with pressure applied by the ultrasound probe in the area of the common bile duct. Dissolution of the biliary calculi was suggested with the use of ursodeoxycholic acid (Ursodial®), in conjunction with close monitoring of patient’s appetite, bilirubin blood concentration, WBC, and the liver enzyme activities, which could indicate a more precarious position of calculi. The patient was eventually euthanized due to persistent seizures, despite several different treatments.